Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008

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PSYCHIATRIC NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB, NurseReview.Org IS NOT RESPONSIBLE FOR ANY TYPOS, WRONG ANSWERS, WRONG RATIONALE, INCONSISTENCIES, ETC.. USE THIS AT YOUR DESGRESSION 1. Mental health is defined as: A. The ability to distinguish what is real from what is not. B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation D. Absence of mental illness Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness. 2. Which of the following describes the role of a technician? A. Administers medications to a schizophrenic patient. B. The nurse feeds and bathes a catatonic client C. Coordinates diverse aspects of care rendered to the patient D. Disseminates information about alcohol and its effects. Answer: (A) Administers medications to a schizophrenic patient. Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher. 3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her: A. Subconscious B. Conscious C. Unconscious D. Ego Answer: (A) Subconscious Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.

4. The superego is that part of the psyche that: A. Uses defensive function for protection. B. Is impulsive and without morals. C. Determines the circumstances before making decisions. D. The censoring portion of the mind. Answer: (D) The censoring portion of the mind. The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego. 5. Primary level of prevention is exemplified by: A. Helping the client resume self care. B. Ensuring the safety of a suicidal client in the institution. C. Teaching the client stress management techniques D. Case finding and surveillance in the community Answer: (C) Teaching the client stress management techniques Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness. 6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask? A. “Are you being threatened or hurt by your partner? B. “Are you frightened of you partner” C. “Is something bothering you?” D. “What happens when you and your partner argue?” Answer: (A) “Are you being threatened or hurt by your partner? The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse. 7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is: A. Sexual desire disorder B. Sexual arousal Disorder C. Orgasm Disorder D. Sexual Pain Disorder Answer: (A) Sexual desire disorder Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.

8. What would be the best approach for a wife who is still living with her abusive husband? A. “Here’s the number of a crisis center that you can call for help .” B. “Its best to leave your husband.” C. “Did you discuss this with your family?” D. “ Why do you allow yourself to be treated this way” Answer: (A) “Here’s the number of a crisis center that you can call for help .” Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault. 9. Which comment about a 3 year old child if made by the parent may indicate child abuse? A. “Once my child is toilet trained, I can still expect her to have some" B. “When I tell my child to do something once, I don’t expect to have to tell" C. “My child is expected to try to do things such as, dress and feed.” D. “My 3 year old loves to say NO.” Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell" Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old. 10. The primary nursing intervention for a victim of child abuse is: A. Assess the scope of the problem B. Analyze the family dynamics C. Ensure the safety of the victim D. Teach the victim coping skills Answer: (C) Ensure the safety of the victim The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later. 11. Situation: A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder? A. Somatization Disorder B. Hypochondriaisis C. Conversion Disorder D. Somatoform Pain Disorder Answer: (D) Somatoform Pain Disorder This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized

by alteration or loss in sensory or motor function resulting from a psychological conflict. 12. Freud explains anxiety as: A. Strives to gratify the needs for satisfaction and security B. Conflict between id and superego C. A hypothalamic-pituitary-adrenal reaction to stress D. A conditioned response to stressors Answer: (B) Conflict between id and superego Freud explains anxiety as due to opposing action drives between the id and the superego. A. Sullivan identified 2 types of needs, satisfaction and security. Failure to gratify these needs may result in anxiety. C. Biomedical perspective of anxiety. D. Explanation of anxiety using the behavioral model. 13. The following are appropriate nursing diagnosis for the client EXCEPT: A. Ineffective individual coping B. Alteration in comfort, pain C. Altered role performance D. Impaired social interaction Answer: (D) Impaired social interaction The client may not have difficulty in social exchange. The cues do not support this diagnosis. A. The client maladaptively uses body symptoms to manage anxiety. B. The client will have discomfort due to pain. C. The client may fail to meet environmental expectations due to pain. 14. The following statements describe somatoform disorders: A. Physical symptoms are explained by organic causes B. It is a voluntary expression of psychological conflicts C. Expression of conflicts through bodily symptoms D. Management entails a specific medical treatment Answer: (C) Expression of conflicts through bodily symptoms Bodily symptoms are used to handle conflicts. A. Manifestations do not have an organic basis. B. This occurs unconsciously. D. Medical treatment is not used because the disorder does not have a structural or organic basis. 15. What would be the best response to the client’s repeated complaints of pain: A. “I know the feeling is real tests revealed negative results.” B. . “I think you’re exaggerating things a little bit.” C. “Try to forget this feeling and have activities to take it off your mind” D. “So tell me more about the pain” Answer: (A) “I know the feeling is real tests revealed negative results.” Shows empathy and offers information. B. This is a demeaning statement. C. This belittles the client’s feelings. D. Giving undue attention to the physical symptom reinforces the complaint. 16. Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital.

When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to: A. provide as much structure as possible for the child B. ignore the child’s overactivity. C. encourage the child to engage in any play activity to dissipate energy D. remove the child from the classroom when disruptive behavior occurs Answer: (A) provide as much structure as possible for the child Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non –confrontational approach and setting limit to time allotted for activities. B. The child will not benefit from a lenient approach. C. Dissipate energy through safe activities. D. This indicates that the classroom environment lacks structure. 17. The child with conduct disorder will likely demonstrate: A. Easy distractibility to external stimuli. B. Ritualistic behaviors C. Preference for inanimate objects. D. Serious violations of age related norms. Answer: (D) Serious violations of age related norms. This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. A. This is characteristic of attention deficit disorder. B and C. These are noted among children with autistic disorder. 18. Ritalin is the drug of choice for chidren with ADHD. The side effects of the following may be noted: A. increased attention span and concentration B. increase in appetite C. sleepiness and lethargy D. bradycardia and diarrhea Answer: (A) increased attention span and concentration The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability. 19. School phobia is usually treated by: A. Returning the child to the school immediately with family support. B. Calmly explaining why attendance in school is necessary C. Allowing the child to enter the school before the other children D. Allowing the parent to accompany the child in the classroom Answer: (A) Returning the child to the school immediately with family support. Exposure to the feared situation can help in overcoming anxiety. A. This will not help in relieving the anxiety due separation from a significant other. C. and C. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. D. This will not help the child overcome the fear 20. A 10 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification:

A. Profound B. Mild C. Moderate D. Severe Answer: (C) Moderate The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35. 21. The nurse teaches the parents of a mentally retarded child regarding her care. The following guidelines may be taught except: A. overprotection of the child B. patience, routine and repetition C. assisting the parents set realistic goals D. giving reasonable compliments Answer: (A) overprotection of the child The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. B,C, and D Children with mental retardation have learning difficulty. They should be taught with patience and repetition, start from simple to complex, use visuals and compliment them for motivation. Realistic expectations should be set and optimize their capability. 22. The parents express apprehensions on their ability to care for their maladaptive child. The nurse identifies what nursing diagnosis: A. hopelessness B. altered parenting role C. altered family process D. ineffective coping Answer: (B) altered parenting role Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. This is reflected in the parent’s inability to care for the child. A. This refers to lack of choices or inability to mobilize one’s resources. C. Refers to change in family relationship and function. D. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources 23. A 5 year old boy is diagnosed to have autistic disorder. Which of the following manifestations may be noted in a client with autistic disorder? A. argumentativeness, disobedience, angry outburst B. intolerance to change, disturbed relatedness, stereotypes C. distractibility, impulsiveness and overactivity D. aggression, truancy, stealing, lying Answer: (B) intolerance to change, disturbed relatedness, stereotypes These are manifestations of autistic disorder. A. These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. C. These are manifestations of Attention Deficit Disorder D. These are the manifestations of Conduct Disorder

24. The therapeutic approach in the care of an autistic child include the following EXCEPT: A. Engage in diversionary activities when acting -out B. Provide an atmosphere of acceptance C. Provide safety measures D. Rearrange the environment to activate the child Answer: (D) Rearrange the environment to activate the child The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be rechannelled through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling. 25. According to Piaget a 5 year old is in what stage of development: A. Sensory motor stage B. Concrete operations C. Pre-operational D. Formal operation Answer: (C) Pre-operational Pre-operational stage (2-7 years) is the stage when the use of language, the use of symbols and the concept of time occur. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. B. Concrete operations (7-12 years) when inductive reasoning develops. D. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop. 26. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates: A. withdrawal B. tolerance C. intoxication D. psychological dependence Answer: (B) tolerance tolerance refers to the increase in the amount of the substance to achieve the same effects. A. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. B. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. D. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms. 27. The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension and fever. The nurse should be alert for impending: A. delirium tremens B. Korsakoff’s syndrome C. esophageal varices D. Wernicke’s syndrome Answer: (A) delirium tremens

Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B C. This is a complication of liver cirrhosis which may be secondary to alcoholism . D. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination. 28. The care for the client places priority to which of the following: A. Monitoring his vital signs every hour B. Providing a quiet, dim room C. Encouraging adequate fluids and nutritious foods D. Administering Librium as ordered Answer: (A) Monitoring his vital signs every hour Pulse and blood pressure are usually elevated during withdrawal, Elevation may indicate impending delirium tremens B. Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. C. Adequate nutrition with sulpplement of Vit. B should be ensured. D. Sedatives are used to relieve anxiety. 29. Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum. A. Heroin B. cocaine C. LSD D. marijuana Answer: (B) cocaine The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations. 30. A client is admitted with needle tracts on his arm, stuporous and with pin point pupil will likely be managed with: A. Naltrexone (Revia) B. Narcan (Naloxone) C. Disulfiram (Antabuse) D. Methadone (Dolophine) Answer: (B) Narcan (Naloxone) Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. A. This is an opiate receptor blocker used to relieve the craving for heroine C. Disulfiram is used as a deterrent in the use of alcohol. D. Methadone is used as a substitute in the withdrawal from heroine 31. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function.

The daughter revealed that the client used her toothbrush to comb her hair. She is manifesting: A. apraxia B. aphasia C. agnosia D. amnesia Answer: (C) agnosia This is the inability to recognize objects. A. Apraxia is the inability to execute motor activities despite intact comprehension. B. Aphasia is the loss of ability to use or understand words. D. Amnesia is loss of memory. 32. She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things.” Which response by the nurse will be most therapeutic? A. ”Don’t take it personally. Your mother does not mean it.” B. “Have you tried discussing this with your mother?” C. “This must be difficult for you and your mother.” D. “Next time ask your mother where her things were last seen.” Answer: (C) “This must be difficult for you and your mother.” This reflecting the feeling of the daughter that shows empathy. A and D. Giving advise does not encourage verbalization. B. This response does not encourage verbalization of feelings. 33. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client: A. receives adequate nutrition and hydration B. will reminisce to decrease isolation C. remains in a safe and secure environment D. independently performs self care Answer: (C) remains in a safe and secure environment Safety is a priority consideration as the client’s cognitive ability deteriorates.. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently 34. She says to the nurse who offers her breakfast, “Oh no, I will wait for my husband. We will eat together” The therapeutic response by the nurse is: A. “Your husband is dead. Let me serve you your breakfast.” B. “I’ve told you several times that he is dead. It’s time to eat.” C. “You’re going to have to wait a long time.” D. “What made you say that your husband is alive? Answer: (A) “Your husband is dead. Let me serve you your breakfast.” The client should be reoriented to reality and be focused on the here and now.. B. This is not a helpful approach because of the short term memory of the client. C. This indicates a pompous response. D. The cognitive limitation of the client makes the client incapable of giving explanation. 35. Dementia unlike delirium is characterized by:

A. slurred speech B. insidious onset C. clouding of consciousness D. sensory perceptual change Answer: (B) insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium. 36. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. Which of the following nursing diagnoses will be given priority for the client? A. altered self-image B. fluid volume deficit C. altered nutrition less than body requirements D. altered family process Answer: (B) fluid volume deficit Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority. 37. What is the best intervention to teach the client when she feels the need to starve? A. Allow her to starve to relieve her anxiety B. Do a short term exercise until the urge passes C. Approach the nurse and talk out her feelings D. Call her mother on the phone and tell her how she feels Answer: (C) Approach the nurse and talk out her feelings The client with anorexia nervosa uses starvation as a way of managing anxiety. Talking out feelings with the nurse is an adaptive coping. A. Starvation should not be encouraged. Physical safety is a priority. Without adequate nutrition, a life threatening situation exists. B. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. Limits should be set on attempts to lose more weight. D. The client may have a domineering mother which causes the client to feel ambivalent. The client will not discuss her feelings with her mother. 38. The client with anorexia nervosa is improving if: A. She eats meals in the dining room. B. Weight gain C. She attends ward activities. D. She has a more realistic self concept. Answer: (B) Weight gain Weight gain is the best indication of the client’s improvement. The goal is for the client to gain 1-2 pounds per week. (A)The client may purge after eating. (C) Attending an activity does not indicate improvement in nutritional state. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement.

39. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals A. have episodic binge eating and purging B. have repeated attempts to stabilize their weight C. have peculiar food handling patterns D. have threatened self-esteem Answer: (A) have episodic binge eating and purging Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. B and C are characteristics of a client with anorexia nervosa D. Low esteem is noted in both eating disorders 40. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. The goal for this problem is: A. Patient will learn problem solving skills B. Patient will have decreased symptoms of anxiety. C. Patient will perform self care activities daily. D. Patient will verbalize how to set limits on others. Answer: (A) Patient will learn problem solving skills if the client learns problem solving skills she will gain a sense of control over her life. (B) Anxiety is caused by powerlessness. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority. 41. In the management of bulimic patients, the following nursing interventions will promote a therapeutic relationship EXCEPT: A. Establish an atmosphere of trust B. Discuss their eating behavior. C. Help patients identify feelings associated with binge-purge behavior D. Teach patient about bulimia nervosa Answer: (B) Discuss their eating behavior. The client is often ashamed of her eating behavior. Discussion should focus on feelings. A,C and D promote a therapeutic relationship 42. Situation: A 35 year old male has intense fear of riding an elevator. He claims “ As if I will die inside.” This has affected his studies The client is suffering from: A. agoraphobia B. social phobia C. Claustrophobia D. xenophobia Answer: (C) Claustrophobia Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers.

43. Initial intervention for the client should be to: A. Encourage to verbalize his fears as much as he wants. B. Assist him to find meaning to his feelings in relation to his past. C. Establish trust through a consistent approach. D. Accept her fears without criticizing. Answer: (D) Accept her fears without criticizing. The client cannot control her fears although the client knows its silly and can joke about it. A. Allow expression of the client’s fears but he should focus on other productive activities as well. B and C. These are not the initial interventions. 44. The nurse develops a countertransference reaction. This is evidenced by: A. Revealing personal information to the client B. Focusing on the feelings of the client. C. Confronting the client about discrepancies in verbal or non-verbal behavior D. The client feels angry towards the nurse who resembles his mother. Answer: (A) Revealing personal information to the client A. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. 45. Which is the desired outcome in conducting desensitization: A. The client verbalize his fears about the situation B. The client will voluntarily attend group therapy in the social hall. C. The client will socialize with others willingly D. The client will be able to overcome his disabling fear. Answer: (D) The client will be able to overcome his disabling fear. The client will overcome his disabling fear by gradual exposure to the feared object. A,B and C are not the desired outcome of desensitization. 46. Which of the following should be included in the health teachings among clients receiving Valium: A. Avoid taking CNS depressant like alcohol. B. There are no restrictions in activities. C. Limit fluid intake. D. Any beverage like coffee may be taken Answer: (A) Avoid taking CNS depressant like alcohol. Valium is a CNS depressant. Taking it with other CNS depressants like alcohol; potentiates its effect. B. The client should be taught to avoid activities that require alertness. C. Valium causes dry mouth so the client must increase her fluid intake. D. Stimulants must not be taken by the client because it can decrease the effect of Valium. 47. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. Extensive examination revealed no physical basis for the complaint. The nurse plans intervention based on which correct statement about conversion disorder?

A. The symptoms are conscious effort to control anxiety B. The client will experience high level of anxiety in response to the paralysis. C. The conversion symptom has symbolic meaning to the client D. A confrontational approach will be beneficial for the client. Answer: (C) The conversion symptom has symbolic meaning to the client the client uses body symptoms to relieve anxiety. A. The condition occurs unconsciously. B. The client is not distressed by the lost or altered body function. D. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety. 48. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. The most therapeutic response by the nurse is: A. “I can refer you to a spiritual counselor if you like.” B. “You shouldn’t allow anyone to pressure you into sex.” C. “It sounds like this problem is related to your paralysis.” D. “How do you feel about being pressured into sex by your boyfriend?” Answer: (D) “How do you feel about being pressured into sex by your boyfriend?” Focusing on expression of feelings is therapeutic. The central force of the client’s condition is anxiety. A. This is not therapeutic because the nurse passes the responsibility to the counselor. B. Giving advice is not therapeutic. C. This is not therapeutic because it confronts the underlying cause. 49. Malingering is different from somatoform disorder because the former: A. Has evidence of an organic basis. B. It is a deliberate effort to handle upsetting events C. Gratification from the environment are obtained. D. Stress is expressed through physical symptoms. Answer: (B) It is a deliberate effort to handle upsetting events Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious. A. Both disorders do not have an organic or structural basis. C. Both have primary gains. D. This is a characteristic of somatoform disorder. 50. Unlike psychophysiologic disorder Linda may be best managed with: A. medical regimen B. milieu therapy C. stress management techniques D. psychotherapy Answer: (C) stress management techniques Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. A. This disorder is not supported by organic pathology so no medical regimen is required. B and D. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best. 51. Which is the best indicator of success in the long term management of the client? A. His symptoms are replaced by indifference to his feelings B. He participates in diversionary activities. C. He learns to verbalize his feelings and concerns D. He states that his behavior is irrational.

Answer: (C) He learns to verbalize his feelings and concerns C. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. A. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. B. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. D. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor, not as irrational. 52. Situation: A young woman is brought to the emergency room appearing depressed. The nurse learned that her child died a year ago due to an accident. The initial nursing diagnosis is dysfunctional grieving. The statement of the woman that supports this diagnosis is: A. “I feel envious of mothers who have toddlers” B. “I haven’t been able to open the door and go into my baby’s room “ C. “I watch other toddlers and think about their play activities and I cry.” D. “I often find myself thinking of how I could have prevented the death. Answer: (B) “I haven’t been able to open the door and go into my baby’s room “ This indicates denial. This defense is adaptive as an initial reaction to loss but an extended, unsuccessful use of denial is dysfunctional. A. This indicates acknowledgement of the loss. Expressing feelings openly is acceptable. C. This indicates the stage of depression in the grieving process. D. Remembering both positive and negative aspects of the deceased love one signals successful mourning. 53. The client said “I can’t even take care of my baby. I’m good for nothing.” Which is the appropriate nursing diagnosis? A. Ineffective individual coping related to loss. B. Impaired verbal communication related to inadequate social skills. C. Low esteem related to failure in role performance D. Impaired social interaction related to repressed anger. Answer: (C) Low esteem related to failure in role performance This indicates the client’s negative self evaluation. A sense of worthlessness may accompany depression. A,B and D are not relevant. The cues do not indicate inability to use coping resources, decreased ability to transmit/process symbols, nor insufficient quality of social exchange 54. The following medications will likely be prescribed for the client EXCEPT: A. Prozac B. Tofranil C. Parnate D. Zyprexa Answer: (D) Zyprexa This is an antipsychotic. A. This is a SSRI antidepressant. B. This antidepressant belongs to the Tricyclic group. C. This is a MAOI antidepressant. 55. Which is the highest priority in the post ECT care?

A. Observe for confusion B. Monitor respiratory status C. Reorient to time, place and person D. Document the client’s response to the treatment Answer: (B) Monitor respiratory status A side effect of ECT which is life threatening is respiratory arrest. A and C. Confusion and disorientation are side effects of ECT but these are not the highest priority. 56. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant talked fast and hyperactive. Initially the nurse should plan this for a manic client: A. set realistic limits to the client’s behavior B. repeat verbal instructions as often as needed C. allow the client to get out feelings to relieve tension D. assign a staff to be with the client at all times to help maintain control Answer: (A) set realistic limits to the client’s behavior The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety. B. Clear, concise directions are given because of the distractibility of the client but this is not the priority. C. The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed D. Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic. 57. An activity appropriate for the client is: A. table tennis B. painting C. chess D. cleaning Answer: (D) cleaning The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension. A. Tennis is a competitive activity which can stimulate the client. 58. The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following: A. Agree on a consistent approach among the staff assigned to the client. B. Suggest that the client take a leading role in the social activities C. Provide the client with extra time for one on one sessions D. Allow the client to negotiate the plan of care Answer: (A) Agree on a consistent approach among the staff assigned to the client. A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed. B. This is not therapeutic because the client tends to control and dominate others. C. Limits are set for interaction time. D. Allowing the client to negotiate may reinforce manipulative behavior.

59. The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. Taking a directive role in verbalizing feelings B. Using an authoritarian, confrontational approach C. Putting the client in a seclusion room D. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. B. This is a threatening approach. C and D. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger. 60. A client on Lithium has diarrhea and vomiting. What should the nurse do first: A. Recognize this as a drug interaction B. Give the client Cogentin C. Reassure the client that these are common side effects of lithium therapy D. Hold the next dose and obtain an order for a stat serum lithium level Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia. 61. Situation: A widow age 28, whose husband died one year ago due to AIDS, has just been told that she has AIDS. Pamela says to the nurse, “Why me? How could God do this to me?” This reaction is one of: A. Depression B. Denial C. anger D. bargaining Answer: (C) anger Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others. A. Depression is a painful stage where the individual mourns for what was lost. B. Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. D. In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…” 62. The nurse’s therapeutic response is: A. “I will refer you to a clergy who can help you understand what is happening to you.” B. “ It isn’t fair that an innocent like you will suffer from AIDS.” C. “That is a negative attitude.” D. ”It must really be frustrating for you. How can I best help you?”

Answer: (D) ”It must really be frustrating for you. How can I best help you?” This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern. A. This is not therapeutic since it passes the buck or responsibility to the clergy. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. C. This statement passes judgment on the client. 63. One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is: A. focusing B. validating C. reflecting D. giving broad opening Answer: (D) giving broad opening Broad opening technique allows the client to take the initiative in introducing the topic. A,B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement. 64. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following: A. anxiety B. suicidal ideation C. Major depression D. Hopelessness Answer: (B) suicidal ideation The client’s statement is a verbal cue of suicidal ideation not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and non verbal cue of the client indicate suicide. 65. Which of the following interventions should be prioritized in the care of the suicidal client? A. Remove all potentially harmful items from the client’s room. B. Allow the client to express feelings of hopelessness. C. Note the client’s capabilities to increase self esteem. D. Set a “no suicide” contract with the client. Answer: (A) Remove all potentially harmful items from the client’s room. Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide. 66. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.K. to work as nurse. The client has which of the following developmental focus: A. Establishing relationship with the opposite sex and career planning. B. Parental and societal responsibilities.

C. Establishing ones sense of competence in school. D. Developing initial commitments and collaboration in work Answer: (A) Establishing relationship with the opposite sex and career planning. The client belongs to the adolescent stage. The adolescent establishes his sense of identity by making decisions regarding familial, occupational and social roles. The adolescent emancipates himself from the family and decides what career to pursue, what set of friends to have and what value system to uphold. B. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. C. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. D. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex, establishment of a safe and congenial family environment and building of one’s lifework. 67. The personality type of Ryan is: A. conforming B. dependent C. perfectionist D. masochistic Answer: (B) dependent A client with dependent personality is predisposed to develop asthma. A. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. C. The perfectionist and compulsive tend to develop migraine. D. The masochistic, self sacrificing type are prone to develop rheumatoid arthritis. 68. The nurse ensures a therapeutic environment for the client. Which of the following best describes a therapeutic milieu? A. A therapy that rewards adaptive behavior B. A cognitive approach to change behavior C. A living, learning or working environment. D. A permissive and congenial environment Answer: (C) A living, learning or working environment. A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. The six environmental elements include structure, safety, norms, limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu. 69. Included as priority of care for the client will be: A. Encourage verbalization of concerns instead of demonstrating them through the body B. Divert attention to ward activities C. Place in semi-fowlers position and render O2 inhalation as ordered D. Help her recognize that her physical condition has an emotional component Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered

Since psychopysiologic disorder has organic basis, priority intervention is directed towards disease-specific management. Failure to address the medical condition of the client may be a life threat. A and B. The client has physical symptom that is adversely affected by psychological factors. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. However, these are not the priority. D. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready. 70. The client is concerned about his coming discharge, manifested by being unusually sad. Which is the most therapeutic approach by the nurse? A. “You are much better than when you were admitted so there’s no reason to worry.” B. “What would you like to do now that you’re about to go home?” C. “You seem to have concerns about going home.” D. “Aren’t you glad that you’re going home soon?” Answer: (C) “You seem to have concerns about going home.” . This statement reflects how the client feels. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.. A. Giving false reassurance is not therapeutic. B. While this technique explores plans after discharge, it does not focus on expression of feelings. D. This close ended question does not encourage verbalization of feelings. 71. Situation: The nurse may encounter clients with concerns on sexuality. The most basic factor in the intervention with clients in the area of sexuality is: A. Knowledge about sexuality. B. Experience in dealing with clients with sexual problems C. Comfort with one’s sexuality D. Ability to communicate effectively Answer: (C) Comfort with one’s sexuality The nurse must be accepting, empathetic and non-judgmental to patients who disclose concerns regarding sexuality. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. A,B and D are important considerations but these are not the priority. 72. Which of the following statements is true for gender identity disorder? A. It is the sexual pleasure derived from inanimate objects. B. It is the pleasure derived from being humiliated and made to suffer C. It is the pleasure of shocking the victim with exposure of the genitalia D. It is the desire to live or involve in reactions of the opposite sex Answer: (D) It is the desire to live or involve in reactions of the opposite sex Gender identity disorder is a strong and persistent desire to be the other sex. A. This is fetishism. B. This refers to masochism. C. This describes exhibitionism. 73. The sexual response cycle in which the sexual interest continues to build: A. Sexual Desire B. Sexual arousal C. Orgasm

D. Resolution Answer: (B) Sexual arousal Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. A. Sexual Desire refers to the ability, interest or willingness for sexual stimulation. C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. D. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state. 74. The inability to maintain the physiologic requirements in sexual intercourse is: A. Sexual Desire Disorder B. Sexual Arousal Disorder C. Orgasm Disorder D. Sexual Pain disorder Answer: (B) Sexual Arousal Disorder This describes sexual arousal disorder. A. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. D. Sexual Pain Disorder is characterized by genital pain before, during or after sexual intercourse. 75. The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is: A. “You’re attractive but I’m not interested.” B. “You wouldn’t be the first that I will see naked.” C. “I will report you to the guard if you don’t control yourself.” D. “I only need access to your arm. Putting up your sleeve is fine.” Answer: (D) “I only need access to your arm. Putting up your sleeve is fine.” The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. A and B. These responses are not therapeutic because they are challenging and rejecting. C. Threatening the client is not therapeutic. 76. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. A nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway and making aggressive remarks. Which of the following statements is most appropriate to make to this patient? A. What is causing you to become agitated? B. You need to stop that behavior now. C. You will need to be restrained if you do not change your behavior. D. You will need to be placed in seclusion. Answer: (A) What is causing you to become agitated? In a non-violent aggressive behavior, help the client identify the stressor or the true object of hostility. This helps reveal unresolved issues so that they may be confronted. B. Pacing is a tension relieving measure for an agitated client. C. This is a threatening statement that can heighten the client’s tension. D. Seclusion is used when less restrictive measures have failed.

77. The nurse closely observes the client who has been displaying aggressive behavior. The nurse observes that the client’s anger is escalating. Which approach is least helpful for the client at this time? A. Acknowledge the client’s behavior B. Maintain a safe distance from the client C. Assist the client to an area that is quiet D. Initiate confinement measures Answer: (D) Initiate confinement measures The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. . When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness, seclusion or restraints may be applicable. A, B and C are appropriate approaches during the escalation phase of aggression. 78. The charge nurse of a psychiatric unit is planning the client assignment for the day. The most appropriate staff to be assigned to a client with a potential for violence is which of the following: A. A timid nurse B. A mature experienced nurse C. an inexperienced nurse D. a soft spoken nurse Answer: (B) A mature experienced nurse The unstable, aggressive client should be assigned to the most experienced nurse. A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient. 79. The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. Taking a directive role in verbalizing feelings B. Using an authoritarian, confrontational approach C. Putting the client in a seclusion room D. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. B. A confrontational approach can be threatening and adds to the client’s tension. C and D. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful. 80. The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights? A. There was a doctor’s order for restraints/seclusion B. The patient’s rights were explained to him. C. The staff observed confidentiality D. The staff carried out less restrictive measures but were unsuccessful. Answer: (D) The staff carried out less restrictive measures but were unsuccessful. This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior.

81. Situation: Clients with personality disorders have difficulties in their social and occupational functions. Clients with personality disorder will most likely: A. recover with therapeutic intervention B. respond to antianxiety medication C. manifest enduring patterns of inflexible behaviors D. Seek treatment willingly from some personally distressing symptoms Answer: (C) manifest enduring patterns of inflexible behaviors Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. This disorder is manifested by life-long patterns of behavior. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. B. Medications are generally not recommended for personality disorders. 82. A client tends to be insensitive to others, engages in abusive behaviors and does not have a sense of remorse. Which personality disorder is he likely to have? A. Narcissistic B. Paranoid C. Histrionic D. Antisocial Answer: (D) Antisocial These are the characteristics of an individual with antisocial personality. A. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. C. Individuals with histrionic have excessive emotionality, and attention-seeking behaviors. 83. The client joins a support group and frequently preaches against abuse, is demonstrating the use of: A. denial B. reaction formation C. rationalization D. projection Answer: (B) reaction formation Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. A. Denial is refusal to accept a painful reality. C. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. D. Projection is attributing of one’s behaviors and feelings to another person. 84. A teenage girl is diagnosed to have borderline personality disorder. Which manifestations support the diagnosis? A. Lack of self esteem, strong dependency needs and impulsive behavior B. social withdrawal, inadequacy, sensitivity to rejection and criticism C. Suspicious, hypervigilance and coldness D. Preoccupation with perfectionism, orderliness and need for control

Answer: (A) Lack of self esteem, strong dependency needs and impulsive behavior These are the characteristics of client with borderline personality. B. This describes the avoidant personality. C. These are the characteristics of a client with paranoid personality D. This describes the obsessive compulsive personality 85. The plan of care for clients with borderline personality should include: A. Limit setting and flexibility in schedule B. Giving medications to prevent acting out C. Restricting her from other clients D. Ensuring she adheres to certain restrictions Answer: (D) Ensuring she adheres to certain restrictions The client is manipulative. The client must be informed about the policies, expectations, rules and regulation upon admission. A. Limits should be firmly and consistently implemented. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. B. There is no specific medication prescribed for this condition. C. This is not part of the care plan. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others. 86. Situation: A 42 year old male client, is admitted in the ward because of bizarre behaviors. He is given a diagnosis of schizophrenia paranoid type. The client should have achieved the developmental task of: A. Trust vs. mistrust B. Industry vs. inferiority C. Generativity vs. stagnation D. Ego integrity vs. despair Answer: (D) Ego integrity vs. despair The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. (A) Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future. 87. Clients who are suspicious primarily use projection for which purpose: A. deny reality B. to deal with feelings and thoughts that are not acceptable C. to show resentment towards others D. manipulate others Answer: (B) to deal with feelings and thoughts that are not acceptable Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. A. This is not true in all instances of projection C and D. This focuses on the self rather than others 88. The client says “ the NBI is out to get me.” The nurse’s best response is:

A. “The NBI is not out to catch you.” B. “I don’t believe that.” C. “I don’t know anything about that. You are afraid of being harmed.” D. “ What made you think of that.” Answer: (C) “I don’t know anything about that. You are afraid of being harmed.” This presents reality and acknowledges the clients feeling A and B. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. unnecessary exploration of the false 89. The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting: A. tardive dyskinesia B. Pseudoparkinsonism C. akinesia D. dystonia Answer: (B) Pseudoparkinsonism Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by masklike facies, pill rolling tremors, muscle rigidity A. Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue C. Akinesia is characterized by feeling of weakness and muscle fatigue D. Dystonia is manifested by torticollis and rolling back of the eyes 90. The client is very hostile toward one of the staff for no apparent reason. The client is manifesting: A. Splitting B. Transference C. Countertransference D. Resistance Answer: (B) Transference Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse 91. Situation: An 18 year old female was sexually attacked while on her way home from work. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. Situational B. Adventitious C. Developmental D. Internal Answer: (B) Adventitious Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Are the same. They are transitional or developmental periods in life

92. During the initial care of rape victims the following are to be considered EXCEPT: A. Assure privacy. B. Touch the client to show acceptance and empathy C. Accompany the client in the examination room. D. Maintain a non-judgmental approach. Answer: (B) Touch the client to show acceptance and empathy The client finds touch intrusive and therefore should be avoided. A. Privacy is one of the rights of a victim of rape. C.The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support. D. Guilt feeling is common among rape victims. They should not be blamed. 93. The nurse acts as a patient advocate when she does one of the following: A. She encourages the client to express her feeling regarding her experience. B. She assesses the client for injuries. C. She postpones the physical assessment until the client is calm D. Explains to the client that her reactions are normal Answer: (C) She postpones the physical assessment until the client is calm The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts a a counselor B. The nurse acts as a technician D. This exemplifies the role of a teacher 94. Crisis intervention carried out to the client has this primary goal: A. Assist the client to express her feelings B. Help her identify her resources C. Support her adaptive coping skills D. Help her return to her pre-rape level of function Answer: (D) Help her return to her pre-rape level of function The goal of crisis intervention to help the client return to her level of function prior to the crisis. A,B and C are interventions or strategies to attain the goal 95. Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from: A. Adjustment disorder B. Somatoform Disorder C. Generalized Anxiety Disorder D. Post traumatic disorder Answer: (D) Post traumatic disorder Post traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month A. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression and work or social impairments. This occurs within 3 months after the event B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months

96. Situation: A 29 year old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus with what the doctor was saying. The nurse assesses the level of anxiety as: A. Mild B. Moderate C. Severe D. Panic Answer: (C) Severe The client’s manifestations indicate severe anxiety. A Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, ability to concentrate and capable of problem solving. B. Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety. D. Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization 97. Anxiety is caused by: A. an objective threat B. a subjectively perceived threat C. hostility turned to the self D. masked depression Answer: (B) a subjectively perceived threat Anxiety is caused by a subjectively perceived threat A. Fear is caused by an objective threat C. A depressed client internalizes hostility D. Mania is due to masked depression 98. It would be most helpful for the nurse to deal with a client with severe anxiety by: A. Give specific instructions using speak in concise statements. B. Ask the client to identify the cause of her anxiety. C. Explain in detail the plan of care developed D. Urge the client to focus on what the nurse is saying Answer: (A) Give specific instructions using speak in concise statements. The client has narrowed perceptual field. L engthy explanations cannot be followed by the client. B. The client will not be able to identify the cause of anxiety C and D. The client has difficulty concentrating and will not be able to focus. 99. Which of the following medications will likely be ordered for the client?” A. Prozac B. Valium C. Risperdal D. Lithium Answer: (B) Valium Antianxiety A. Antidepressant C. Antipsychotic D. Antimanic 100. Which of the following is included in the health teachings among clients

receiving Valium?: A. Avoid foods rich in tyramine. B. Take the medication after meals. C. It is safe to stop it anytime after long term use. D. Double up the dose if the client forgets her medication. Answer: (B) Take the medication after meals. Antianxiety medications cause G.I. upset so it should be taken after meals. A. This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis. C. Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion. D The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.

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Thursday, November 20, 2008

Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review)
If you're new here, you may want to subscribe to my RSS feed. One advantage of subscribing to RSS feeds is that you don't have to constantly re-visit this site to check for updates within specific sections you might be interested in because your browser or Feed reader will do this for you automatically on a regular basis plus you can even get email notification. Thank you so much. Enjoy! If you like this post, Digg It! Click on the Digg button. MEDICAL SURGICAL NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB, NurseReview.Org IS NOT RESPONSIBLE FOR ANY TYPOS, WRONG ANSWERS, WRONG RATIONALE, INCONSISTENCIES, ETC.. USE THIS AT YOUR DESGRESSION 1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be: A. “Pain will become less each day.” B. “This is a normal reaction after surgery.” C. “With a pillow, apply pressure against the incision.” D. “I will give you the pain medication the physician ordered.” Answer: (C) “With a pillow, apply pressure against the incision.” Applying pressure against the incision with a pillow will help lessen the intraabdominal pressure created by coughing which causes tension on the incision that leads to pain. 2. The nurse needs to carefully assess the complaint of pain of the elderly because older people A. are expected to experience chronic pain B. have a decreased pain threshold C. experience reduced sensory perception D. have altered mental function Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.

3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate. 4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? A. Put the client in modified Trendelenberg's position. B. Administer oxygen at 100%. C. Monitor urine output every hour. D. Administer Demerol 50mg IM q4h Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse. 5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach? A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?" B. "Mr, Pablo, you must be so worried, I'll leave you alone with your thoughts. C. “Mr. Pablo, you'll wear out the hospital floors and yourself at this rate." D. "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns. 6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take? A. Call the physician immediately. B. Administer the prescribed antiemetic. C. Check the patency of the nasogastric tube for any obstruction. D. Change the patient’s position. Answer: (C) Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any

obstruction will help the nurse determine the cause of the problem and institute the necessary intervention. 7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to: A. Reassure him that the nurses will not hurt him B. Let him perform his own activities of daily living C. Handle him gently when assisting with required care D. Complete A.M. care quickly as possible when necessary Answer: (C) Handle him gently when assisting with required care Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently. 8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate? A. Notify his physician. B. Take his vital signs again in 15 minutes. C. Take his vital signs again in an hour. D. Place the patient in shock position. Answer: (B) Take his vital signs again in 15 minutes. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. 9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: A. Reactive pupils B. A depressed fontanel C. Bleeding from ears D. An elevated temperature Answer: (C) Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation 10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD? A. “I exercise every other day.”

B. “My father died of Myasthenia Gravis.” C. “My cholesterol is 180.” D. “I smoke 1 1/2 packs of cigarettes per day.” Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention. 11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug? A. It has positive inotropic and negative chronotropic effects B. The positive inotropic effect will decrease urine output C. Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems D. Do not give the drug if the apical rate is less than 60 beats per minute. Answer: (B) The positive inotropic effect will decrease urine output Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output. 12. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva's maneuver? A. Use of stool softeners. B. Enema administration C. Gagging while toothbrushing. D. Lifting heavy objects Answer: (A) Use of stool softeners. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver. 13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. take the pulse rate once a day, in the morning upon awakening B. may be allowed to use electrical appliances C. have regular follow up care D. may engage in contact sports Answer: (D) may engage in contact sports The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. 14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching? A. “When your chest pain begins, lie down, and place one tablet under your

tongue. If the pain continues, take another tablet in 5 minutes.” B. “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.” C. “Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.” D. “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention. 15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food? A. Whole milk B. Canned sardines C. Plain nuts D. Eggs Answer: (B) Canned sardines Canned foods are generally rich in sodium content as salt is used as the main preservative. 16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate? A. Apply a heating pad to the involved site. B. Elevate the client's legs 90 degrees. C. Instruct the client about the need for bed rest. D. Provide active range-of-motion exercises to both legs at least twice every shift. Answer: (C) Instruct the client about the need for bed rest. In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. 17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client? A. It dissolves existing thrombi. B. It prevents conversion of factors that are needed in the formation of clots. C. It inactivates thrombin that forms and dissolves existing thrombi. D. It interferes with vitamin K absorption. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot. 18. The nurse is conducting an education session for a group of smokers in a

“stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? : A. Dyspnea on exertion B. Foamy, blood-tinged sputum C. Wheezing sound on inspiration D. Cough or change in a chronic cough Answer: (D) Cough or change in a chronic cough Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection. 19. Which is the most relevant knowledge about oxygen administration to a client with COPD? A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. C. Oxygen is administered best using a non-rebreathing mask D. Blood gases are monitored using a pulse oximeter. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive. 20. When suctioning mucus from a client's lungs, which nursing action would be least appropriate? A. Lubricate the catheter tip with sterile saline before insertion. B. Use sterile technique with a two-gloved approach C. Suction until the client indicates to stop or no longer than 20 second D. Hyperoxygenate the client before and after suctioning Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. 21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to A. Cause less irritation to the gastrointestinal tract B. Destroy resistant organisms and promote proper blood levels of the drugs C. Gain a more rapid systemic effect D. Delay resistance and increase the tuberculostatic effect Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A

prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance. 22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler's position on either his right side or on his back to A. Reduce incisional pain. B. Facilitate ventilation of the left lung. C. Equalize pressure in the pleural space. D. Increase venous return Answer: (B) Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. 23. A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT A. Breath in and out as fully as possible before placing the mouthpiece inside the mouth. B. Inhale slowly through the mouth as the canister is pressed down C. Hold his breath for about 10 seconds before exhaling D. Slowly breath out through the mouth with pursed lips after inhaling the drug. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness. 24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse's highest priority of information would be A. Food and fluids will be withheld for at least 2 hours. B. Warm saline gargles will be done q 2h. C. Coughing and deep-breathing exercises will be done q2h. D. Only ice chips and cold liquids will be allowed initially. Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. 25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client's nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?

A. Take heart rate and blood pressure. B. Call the physician. C. Lower the oxygen rate. D. Position the client in a Fowler's position. Answer: (C) Lower the oxygen rate. The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR. 26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient? A. Fluid volume deficit B. Decreased tissue perfusion. C. Impaired gas exchange. D. Risk for infection Answer: (C) Impaired gas exchange. Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess. 27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity? A. large thighs and upper arms B. pendulous abdomen and large hips C. abdominal striae and ankle enlargement D. posterior neck fat pad and thin extremities Answer: (D) posterior neck fat pad and thin extremities “Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome. 28. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy? A. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug.” B. “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” C. “This medicine will protect me from getting any colds or infection.” D. “My incision will heal much faster because of this drug.” Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis 29. A client, who is suspected of having Pheochromocytoma, complains of

sweating, palpitation and headache. Which assessment is essential for the nurse to make first? A. Pupil reaction B. Hand grips C. Blood pressure D. Blood glucose Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure. 30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to: A. Encourage the guest to eat some baked macaroni B. Call the guest’s personal physician C. Offer the guest a cup of coffee D. Give the guest a glass of orange juice Answer: (D) Give the guest a glass of orange juice In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV. 31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be: A. “The medication will limit thyroid hormone secretion.” B. “The medication limit synthesis of the thyroid hormones.” C. “The medication will block the cardiovascular symptoms of Grave’s disease.” D. “The medication will increase the synthesis of thyroid hormones.” Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease. 32. During the first 24 hours after thyroid surgery, the nurse should include in her care: A. Checking the back and sides of the operative dressing B. Supporting the head during mild range of motion exercise C. Encouraging the client to ventilate her feelings about the surgery D. Advising the client that she can resume her normal activities immediately Answer: (A) Checking the back and sides of the operative dressing Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry

and clear of drainage. 33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight gain D. Insomnia and excitability Answer: (C) Progressive weight gain Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain. 34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin? A. Lipodystrophy can result and is extremely painful B. Poor rotation technique can cause superficial hemorrhaging C. Lipodystrophic areas can result, causing erratic insulin absorption rates from these D. Injection sites can never be reused Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions. 35. Which of the following would be inappropriate to include in a diabetic teaching plan? A. Change position hourly to increase circulation B. Inspect feet and legs daily for any changes C. Keep legs elevated on 2 pillows while sleeping D. Keep the insulin not in use in the refrigerator Answer: (C) Keep legs elevated on 2 pillows while sleeping The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment. 36. Included in the plan of care for the immediate post-gastroscopy period will be: A. Maintain NGT to intermittent suction B. Assess gag reflex prior to administration of fluids C. Assess for pain and medicate as ordered D. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.

36. Included in the plan of care for the immediate post-gastroscopy period will be: A. Maintain NGT to intermittent suction B. Assess gag reflex prior to administration of fluids C. Assess for pain and medicate as ordered D. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration. 37. Which description of pain would be most characteristic of a duodenal ulcer? A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake B. RUQ pain that increases after meal C. Sharp pain in the epigastric area that radiates to the right shoulder D. A sensation of painful pressure in the midsternal area Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake. 38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to: A. Reposition the NGT by advancing it gently NSS B. Notify the MD of your findings C. Irrigate the NGT with 50 cc of sterile D. Discontinue the low-intermittent suction Answer: (B) Notify the MD of your findings The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention. 39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care? A. Sit upright for at least 30 minutes after meals B. Take only sips of H2O between bites of solid food C. Eat small meals every 2-3 hours D. Reduce the amount of simple carbohydrate in the diet Answer: (A) Sit upright for at least 30 minutes after meals The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of

food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome. 40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data? A. Treatment will include Ranitidine and Antibiotics B. No treatment is necessary at this time C. This result indicates gastric cancer caused by the organism D. Surgical treatment is necessary Answer: (A) Treatment will include Ranitidine and Antibiotics One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer. 41. What instructions should the client be given before undergoing a paracentesis? A. NPO 12 hours before procedure B. Empty bladder before procedure C. Strict bed rest following procedure D. Empty bowel before procedure Answer: (B) Empty bladder before procedure Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure. 42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet? A. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” B. “The liver heals better with a high carbohydrates diet rather than protein.” C. “Most people have too much protein in their diets. The amount of this diet is better for liver healing.” D. “Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.” Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production. 43. Which of the drug of choice for pain controls the patient with acute pancreatitis? A. Morphine B. NSAIDS C. Meperidine

D. Codeine Answer: (C) Meperidine Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic. 44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is: A. encouraging the client to take adequate deep breaths by mouth B. encouraging the client to cough and deep breathe C. changing the dressing at least BID D. irrigate the T-tube frequently Answer: (B) encouraging the client to cough and deep breathe Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications. 45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to: A. Deflate the esophageal balloon B. Monitor VS C. Encourage him to take deep breaths D. Notify the MD Answer: (A) Deflate the esophageal balloon When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction 46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease? A. Chrons disease B. Ulcerative colitis C. Diverticulitis D. Peritonitis Answer: (B) Ulcerative colitis Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem. 47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:

A. Give laxative the night before and a cleansing enema in the morning before the test B. Render an oil retention enema and give laxative the night before C. Instruct the client to swallow 6 radiopaque tablets the evening before the study D. Place the client on CBR a day before the study Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema. 48. The client has a good understanding of the means to reduce the chances of colon cancer when he states: A. “I will exercise daily.” B. “I will include more red meat in my diet.” C. “I will have an annual chest x-ray.” D. “I will include more fresh fruits and vegetables in my diet.” Answer: (D) “I will include more fresh fruits and vegetables in my diet.” Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer. 49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to A. Cover the wound with sterile, moist saline dressing B. Approximate the wound edges with tapes C. Irrigate the wound with sterile saline D. Hold the abdominal contents in place with a sterile gloved hand Answer: (A) Cover the wound with sterile, moist saline dressing Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process. 50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to A. Strain all urine. B. Ambulate. C. Remain on bed rest. D. Ask for medications to relax him.

Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination. 51. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance? A. Hyponatremia B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia Answer: (A) Hyponatremia The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting 52. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure? A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained. 53. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt? A. Heparinize it daily. B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm. Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.

54. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? A. TURP is the most common operation for BPH. B. Explain the purpose and function of a two-way irrigation system. C. Expect bloody urine, which will clear as healing takes place. D. He will be pain free. Answer: (D) He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance. 55. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney’s point, which is located in the A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant Answer: (C) right lower quadrant To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant. 56. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include A. telling him to avoid heavy lifting for 4 to 6 weeks B. instructing him to have a soft bland diet for two weeks C. telling him to resume his previous daily activities without limitations D. recommending him to drink eight glasses of water daily Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case. 57. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned? A. 18% B. 22% C. 31% D. 40% Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned, we allot the

following: 9% - head; 9% - each upper extremity; 18%- front chest and abdomen; 18% - entire back; 18% - each lower extremity and 1% - perineum. 58. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: A. An increase in the total volume of intracranial plasma B. Excessive renal perfusion with diuresis C. Fluid shift from interstitial space D. Fluid shift from intravascular space to the interstitial space Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output. 59. If a client has severe bums on the upper torso, which item would be a primary concern? A. Debriding and covering the wounds B. Administering antibiotics C. Frequently observing for hoarseness, stridor, and dyspnea D. Establishing a patent IV line for fluid replacement Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern. 60. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures? A. Changing the location of the bed or the TV set, or both, daily B. Encouraging the client to chew gum and blow up balloons C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension D. Helping the client to rest in the position of maximal comfort Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications. 61. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential? A. evaluation of the peripheral IV site B. confirmation that the tube is in the stomach C. assess the bowel sound

D. fluid and electrolyte monitoring Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight. 62. Which drug would be least effective in lowering a client's serum potassium level? A. Glucose and insulin B. Polystyrene sulfonate (Kayexalate) C. Calcium glucomite D. Aluminum hydroxide Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects. 63. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose A. 0.45% NaCl B. 0.9% NaCl C. D5W D. D5NSS Answer: (A) 0.45% NaCl Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood. 64. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT A. hypertension B. oliguria C. tachycardia D. tachypnea Answer: (A) hypertension In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria. 65. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of

A. assuring Maria that she will be cured of cancer B. assessing Maria's expectations and doubts C. maintaining a cheerful and optimistic environment D. keeping Maria's visitors to a minimum so she can have time for herself Answer: (B) assessing Maria's expectations and doubts Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed. 66. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should A. call the MD to change the dressing so Kathy can see the incision B. recognize that Kathy is experiencing denial, a normal stage of the grieving process C. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery. D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization. 67. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true? A. it is a local treatment affecting only tumor cells B. it affects both normal and tumor cells C. it has been proven as a complete cure for cancer D. it is often used as a palliative measure. Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression. 68. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. C. CT scanning uses magnetic fields and radio frequencies to provide crosssectional view of tumor D. Endoscopy provides direct view of a body cavity to detect abnormality. Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor

CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors. 69. A post-operative complication of mastectomy is lymphedema. This can be prevented by A. ensuring patency of wound drainage tube B. placing the arm on the affected side in a dependent position C. restricting movement of the affected arm D. frequently elevating the arm of the affected side above the level of the heart. Answer: (D) frequently elevating the arm of the affected side above the level of the heart. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling. 70. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix? A. “I should get out of bed and walk around in my room.” B. “My 7 year old twins should not come to visit me while I’m receiving treatment.” C. “I will try not to cough, because the force might make me expel the application.” D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.” Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.” Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself. 71. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by: A. The inability of the kidneys to excrete the drug metabolites B. Rapid cell catabolism C. Toxic effect of the antibiotic that are given concurrently D. The altered blood ph from the acid medium of the drugs Answer: (B) Rapid cell catabolism One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure. 72. Which of the following interventions would be included in the care of plan in a client with cervical implant?

A. Frequent ambulation B. Unlimited visitors C. Low residue diet D. Vaginal irrigation every shift Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions 73. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? A. Avoid BP measurement and constricting clothing on the affected arm B. Active range of motion exercises of the arms once a day. C. Discourage feeding, washing or combing with the affected arm D. Place the affected arm in a dependent position, below the level of the heart Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm 74. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of A. Hypervolemia, hypokalemia, and hypernatremia. B. Hypervolemia, hyperkalemia, and hypernatremia. C. Hypovolemia, wide fluctuations in serum sodium and potassium levels. D. Hypovolemia, no fluctuation in serum sodium and potassium levels. Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur. 75. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? A. A rapid pulse and increased RR B. Decreased physiologic functioning C. Rigid posture and altered perceptual focus D. Increased awareness and attention Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for

survival. 76. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be A. placing her in a trendeleburg position B. putting several warm blankets on her C. monitoring her hourly urine output D. assessing her VS especially her RR Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications. 77. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is A. Elevated hematocrit levels. B. Urine output of 30 to 50 ml/hr. C. Change in level of consciousness. D. Estimate of fluid loss through the burn eschar. Answer: (B) Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance. 78. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal. 79. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except

A. administering an irritant that will stimulate vomiting B. aspirating secretions from the pharynx if respirations are affected C. neutralizing the chemical D. washing the esophagus with large volumes of water via gastric lavage Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed. 80. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? A. Skin warm and dry B. Pupils equal and react to light C. Palpable carotid pulse D. Positive Babinski's reflex Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after. 81. Chemical burn of the eye are treated with A. local anesthetics and antibacterial drops for 24 – 36 hrs. B. hot compresses applied at 15-minute intervals C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water D. cleansing the conjunctiva with a small cotton-tipped applicator Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done. 82. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: A. Force air out of the lungs B. Increase systemic circulation C. Induce emptying of the stomach D. Put pressure on the apex of the heart Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.

83. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should: A. ask them to stay in the waiting area until she can spend time alone with them B. speak to both parents together and encourage them to support each other and express their emotions freely C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death. Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another. 84. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to: A. increase BP B. decrease mucosal swelling C. relax the bronchial smooth muscle D. decrease bronchial secretions Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. 85. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the A. upper half of the sternum B. upper third of the sternum C. lower half of the sternum D. lower third of the sternum Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration. 86. The nurse is performing an eye examination on an elderly client. The client states ‘My vision is blurred, and I don’t easily see clearly when I get into a dark room.” The nurse best response is: A. “You should be grateful you are not blind.” B. “As one ages, visual changes are noted as part of degenerative changes. This is normal.”

C. “You should rest your eyes frequently.” D. “You maybe able to improve you vision if you move slowly.” Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.” Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision. 87. Which of the following activities is not encouraged in a patient after an eye surgery? A. sneezing, coughing and blowing the nose B. straining to have a bowel movement C. wearing tight shirt collars D. sexual intercourse Answer: (D) sexual intercourse To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP. 88. Which of the following indicates poor practice in communicating with a hearing-impaired client? A. Use appropriate hand motions B. Keep hands and other objects away from your mouth when talking to the client C. Speak clearly in a loud voice or shout to be heard D. Converse in a quiet room with minimal distractions Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly. 89. A client is to undergo lumbar puncture. Which is least important information about LP? A. Specimens obtained should be labeled in their proper sequence. B. It may be used to inject air, dye or drugs into the spinal canal. C. Assess movements and sensation in the lower extremities after the D. Force fluids before and after the procedure. Answer: (D) Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure. 90. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT A. Inform the client that a warm, flushed feeling and a salty taste may be B. Maintain pressure dressing over the site of puncture and check for C. Check pulse, color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding.

Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site. 91. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for? A. abnormal respiratory pattern B. rising systolic and widening pulse pressure C. contralateral hemiparesis and ipsilateral dilation of the pupils D. progression from restlessness to confusion and disorientation to lethargy Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness. 92. Which is irrelevant in the pharmacologic management of a client with CVA? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a completed stroke. Answer: (D) Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding. 93. What would be the MOST therapeutic nursing action when a client’s expressive aphasia is severe? A. Anticipate the client wishes so she will not need to talk B. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. Encourage the client to speak at every possible opportunity. Answer: (D) Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively. 94. A client with head injury is confused, drowsy and has unequal pupils. Which

of the following nursing diagnosis is most important at this time? A. altered level of cognitive function B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage. 95. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? A. Pain B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation. 96. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF? A. Measure the ph of the fluid B. Measure the specific gravity of th e fluid C. Test for glucose D. Test for chlorides Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage. 97. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan? A. Wash, dry, and inspect the stump daily. B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. D. Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool). Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal

end of the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. 98. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client? A. Decrease the calorie count of her daily diet. B. Take warm baths when arising. C. Slide items across the floor rather than lift them. D. Place items so that it is necessary to bend or stretch to reach them. Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Overreaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient. 99. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority? A. Apply hot compresses to the affected joints. B. Stress the importance of maintaining good posture to prevent deformities. C. Administer salicylates to minimize the inflammatory reaction. D. Ensure an intake of at least 3000 ml of fluid per day. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones. 100. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care? A. Before log rolling, place a pillow under the client's head and a pillow between the client's legs. B. Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. C. Keep the knees slightly flexed while the client is lying in a semi-Fowler's position in bed. D. Keep a pillow under the client's head as needed for comfort. Answer: (B) Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.

101. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care? A. providing emotional support to decrease fear B. protecting the client from infection C. encouraging discussion about lifestyle changes D. identifying factors that decreased the immune function Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection. 102. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery. After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at: A. 25 gtt/min B. 30 gtt/min C. 35 gtt/min D. 45 gtt/min Answer: (A) 25 gtt/min To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20) 103. The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when: A. Fats are controlled in the diet B. Eating habits are altered C. Carbohydrates are regulated D. Exercise is part of the program Answer: (B) Eating habits are altered For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued 104. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will: A. Increase her lean body mass B. Lower her metabolic rate C. Decrease her appetite D. Raise her heart rate Answer: (A) Increase her lean body mass

Increased exercise builds skeletal muscle mass and reduces excess fatty tissue. 105. The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is: A. Exercising the triceps, finger flexors, and elbow extensors B. Sitting up at the edge of the bed to help strengthen back muscles C. Doing isometric exercises on the unaffected leg D. Using the trapeze frequently for pull-ups to strengthen the biceps muscles Answer: (A) Exercising the triceps, finger flexors, and elbow extensors These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation. 106. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on: A. The palms and axillary regions B. Both feet placed wide apart C. The palms of her hands D. Her axillary regions Answer: (C) The palms of her hands The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus) 107. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed. The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer: A. 8 minims B. 10 minims C. 12 minims D. 15 minims Answer: (C) 12 minims Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate 108. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it: A. Will help prevent erratic heart beats B. Relieves pain and decreases level of anxiety C. Decreases anxiety D. Dilates coronary blood vessels

Answer: (B) Relieves pain and decreases level of anxiety Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand. 109. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen: A. Converts to an alternate form of matter B. Has unstable properties C. Supports combustion D. Is flammable Answer: (C) Supports combustion The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use. 110. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is: A. SGPT B. LDH C. CK-MB D. AST Answer: (C) CK-MB The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage. 111. An early finding in the EKG of a client with an infarcted mycardium would be: A. Disappearance of Q waves B. Elevated ST segments C. Absence of P wave D. Flattened T waves Answer: (B) Elevated ST segments This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI. 112. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to: A. Allow him to release his feelings and then leave him alone to allow him to regain his composure B. Refocus the conversation on his fears, frustrations and anger about his

condition C. Explain how his being upset dangerously disturbs his need for rest D. Attempt to explain the purpose of different hospital routines Answer: (B) Refocus the conversation on his fears, frustrations and anger about his condition This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand. 113. Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including: A. Shortness of breath B. Chest pain C. Elevated blood pressure D. Increased pulse rate Answer: (D) Increased pulse rate Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever. 114. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to: A. Suggest he discuss his feelings of vulnerability with his physician. B. Tell him that he certainly needs to be especially careful about his diet and lifestyle. C. Avoid giving him direct information and help him explore his feelings D. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor. Answer: (C) Avoid giving him direct information and help him explore his feelings To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs. 115. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to: A. Store vitamin B12 B. Digest vitamin B12 C. Absorb vitamin B12 D. Produce vitamin B12 Answer: (C) Absorb vitamin B12 Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach

due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine. 116. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer: A. 0.5 ml B. 1.0 ml C. 1.5 ml D. 2.0 ml Answer: (D) 2.0 ml First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin. 117. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include: A. Oral tablets of Vitamin B12 will control her symptoms B. IM injections are required for daily control C. IM injections once a month will maintain control D. Weekly Z-track injections provide needed control Answer: (C) IM injections once a month will maintain control Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow 118. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it: A. When she feels fatigued B. During exacerbations of anemia C. Until her symptoms subside D. For the rest of her life Answer: (D) For the rest of her life Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life. 119. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as: A. Reaction Formation B. Sublimation C. Intellectualization

D. Projection Answer: (D) Projection Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition. 120. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure: A. When the client would have normally had a bowel movement B. After the client accepts he had a bowel movement C. Before breakfast and morning care D. At least 2 hours before visitors arrive Answer: (A) When the client would have normally had a bowel movement Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit. 121. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he: A. Stops the flow of fluid when he feels uncomfortable B. Lubricates the tip of the catheter before inserting it into the stoma C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient. 122. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician : A. Abdominal cramps during fluid inflow B. Difficulty in inserting the irrigating tube C. Passage of flatus during expulsion of feces D. Inability to complete the procedure in half an hour Answer: (B) Difficulty in inserting the irrigating tube Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour. 123. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing: A. A reaction formation to his recent altered body image. B. A difficult time accepting reality and is in a state of denial. C. Impotency due to the surgery and needs sexual counseling

D. Suicide thoughts and should be seen by psychiatrist Answer: (B) A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported 124. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat: A. Food low in fiber so that there is less stool B. Everything he ate before the operation but will avoid those foods that cause gas C. Bland foods so that his intestines do not become irritated D. Soft foods that are more easily digested and absorbed by the large intestines Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided. 125. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are: A. Level of consciousness and pupil size B. Abdominal contusions and other wounds C. Pain, Respiratory rate and blood pressure D. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished 126. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to: A. Facilitate his verbal communication B. Maintain sterility of the ventilation system C. Assess his response to the equipment D. Prepare him for emergency surgery Answer: (C) Assess his response to the equipment It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding

127. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to A. Prepare for chest tube removal B. Milk the tube toward the collection container as ordered C. Arrange for a stat Chest x-ray film. D. Clam the tube immediately Answer: (B) Milk the tube toward the collection container as ordered This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber 128. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is: A. Increased breath sounds B. Constant bubbling in the drainage chamber C. Crepitus detected on palpation of chest D. Increased respiratory rate Answer: (A) Increased breath sounds The chest tube normalizes intrathoracic pressure and restores negative intrapleural pressure, drains fluid and air from the pleural space, and improves pulmonary function 129. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is: A. Urinary output is 30 ml in an hour B. Central venous pressure reading of 2 cm H2O C. Pulse rates of 120 and 110 in a 15 minute period D. Blood pressure readings of 50/30 and 70/40 within 30 minutes Answer: (A) Urinary output is 30 ml in an hour A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain. 130. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the: A. Complete safety of the procedure B. Expectation of postoperative bleeding C. Risk of the procedure with his other injuries D. Presence of abdominal drains for several days after surgery Answer: (D) Presence of abdominal drains for several days after surgery Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

131. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should: A. Encourage bed rest with active and passive range of motion exercises B. Encourage frequent coughing and deep breathing C. Turn him from side to side at least every 2 hours D. Continue observing for dyspnea and crepitus Answer: (B) Encourage frequent coughing and deep breathing This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange. 132. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to: A. Give him explanations of why there is a need to quickly increase his activity B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle C. Appear cheerful and non-critical regardless of his response to attempts at intervention D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention. 133. The key factor in accurately assessing how body image changes will be dealt with by the client is the: A. Extent of body change present B. Suddenness of the change C. Obviousness of the change D. Client’s perception of the change Answer: (D) Client’s perception of the change It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings. 134. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as: A. Reaction formation B. Sublimation C. Intellectualization D. Projection

Answer: (C) Intellectualization People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets. 135. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to: A. Increase his activity level and ambulate frequently B. Sleep with the head of his bed slightly elevated C. Drink citrus juices frequently for nourishment D. Use a soft toothbrush and electric razor Answer: (D) Use a soft toothbrush and electric razor Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression. 136. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing: A. An anaphylactic transfusion reaction B. An allergic transfusion reaction C. A hemolytic transfusion reaction D. A pyrogenic transfusion reaction Answer: (C) A hemolytic transfusion reaction This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations. 137. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be: A. “Your laugher is a cover for your fear.” B. “He who laughs on the outside, cries on the inside.” C. “Why are you always laughing?” D. “Does it help you to joke about your illness?” Answer: (D) “Does it help you to joke about your illness?” This non-judgmentally on the part of the nurse points out the client’s behavior. 138. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to: A. Agree with and encourage the client’s denial B. Reassure the client that everything will be okay C. Allow the denial but be available to discuss death D. Leave the client alone to discuss the loss Answer: (C) Allow the denial but be available to discuss death This does not take away the client’s only way of coping, and it permits future

movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages. 139. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be: A. +55 ml B. +137 ml C. +235 ml D. +485 ml Answer: (C) +235 ml The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake 140. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find: A. Crushing chest pain B. Dyspnea on exertion C. Extensive peripheral edema D. Jugular vein distention Answer: (B) Dyspnea on exertion Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion. 141. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the: A. Distal tubule B. Collecting duct C. Glomerulus of the nephron D. Ascending limb of the loop of Henle Answer: (D) Ascending limb of the loop of Henle This is the site of action of Lasix being a potent loop diuretic. 142. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is: A. 0.5 L B. 1.0 L C. 2.0 L D. 3.5 L Answer: (C) 2.0 L One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

143. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the: A. Diuretic B. Vasodilator C. Bed-rest regimen D. Cardiac glycoside Answer: (D) Cardiac glycoside A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate. 144. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately: A. 2200 calories B. 2000 calories C. 2800 calories D. 1600 calories Answer: (B) 2000 calories There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein 145. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of: A. Magnesium B. Sodium C. Potassium D. Calcium Answer: (B) Sodium Restriction of sodium reduces the amount of water retention that reduces the cardiac workload 146. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be: A. The medications he has been taking B. Any recent foreign travel C. His usual dietary pattern D. His working patterns Answer: (A) The medications he has been taking Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use 147. The meal pattern that would probably be most appropriate for a client

recovering from GI bleeding is: A. Three large meals large enough to supply adequate energy. B. Regular meals and snacks to limit gastric discomfort C. Limited food and fluid intake when he has pain D. A flexible plan according to his appetite Answer: (B) Regular meals and snacks to limit gastric discomfort Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding. 148. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by: A. Increasing HCO3 B. Decreasing PCO2 C. Decreasing pH D. Decreasing PO2 Answer: (B) Decreasing PCO2 Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis. 149. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately: A. 400 Kilocalories B. 600 Kilocalories C. 800 Kilocalories D. 1000 Kilocalories Answer: (B) 600 Kilocalories Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need. 150. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by: A. Encouraging adequate fluids B. Applying elastic stockings C. Massaging gently the legs with lotion D. Performing active-assistive leg exercises Answer: (D) Performing active-assistive leg exercises Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon 151. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a

potential danger. The nurse can best plan to avoid this problem by: A. Emptying the drainage bag frequently B. Collecting a weekly urine specimen C. Maintaining the ordered hydration D. Assessing urine specific gravity Answer: (C) Maintaining the ordered hydration Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection 152. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform: A. Flexion, extension and left and right rotation B. Abduction, flexion, adduction and extension C. Pronation, supination, rotation, and extension D. Dorsiflexion, plantar flexion, eversion and inversion Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion These movements include all possible range of motion for the ankle joint 153. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of: A. 30 degrees B. 45 degrees C. 60 degrees D. 90 degrees Answer: (A) 30 degrees Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores. 154. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery: A. Urinary control may be permanently lost to some degree B. Urinary drainage will be dependent on a urethral catheter for 24 hours C. Frequency and burning on urination will last while the cystotomy tube is in place D. His ability to perform sexually will be permanently impaired Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding. 155. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:

A. Changing the abdominal dressing B. Maintaining patency of the cystotomy tube C. Maintaining patency of a three-way Foley catheter for cystoclysis D. Observing for hemorrhage and wound infection Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis 156. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is: A. Sepsis B. Hemorrhage C. Leakage around the catheter D. Urinary retention with overflow Answer: (B) Hemorrhage After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed. 157. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to: A. Limit discomfort B. Provide hemostasis C. Reduce bladder spasms D. Promote urinary drainage Answer: (B) Provide hemostasis The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding. 158. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to: A. Irrigate the catheter with saline B. Milk the catheter tubing C. Remove the catheter D. Notify the physician Answer: (B) Milk the catheter tubing Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency. 159. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:” A. Get out of bed into a chair for several hours daily B. Call the physician if my urinary stream decreases

C. Attempt to void every 3 hours when I’m awake D. Avoid vigorous exercise for 6 months after surgery Answer: (B) Call the physician if my urinary stream decreases Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction. 160. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find: A. Lethargy, weight gain, and forgetfulness B. Weight loss, protruding eyeballs, and lethargy C. Weight loss, exopthalmos and restlessness D. Constipation, dry skin, and weight gain Answer: (C) Weight loss, exopthalmos and restlessness Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema. 161. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy: A. The entire thyroid gland is removed B. A small part of the gland is left intact C. One parathyroid gland is also removed D. A portion of the thyroid and four parathyroids are removed Answer: (B) A small part of the gland is left intact Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca. 162. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include: A. A crash cart with bed board B. A tracheostomy set and oxygen C. An airway and rebreathing mask D. Two ampules of sodium bicarbonate Answer: (B) A tracheostomy set and oxygen Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany. 163. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: A. Observing for signs of tetany B. Checking her throat for swelling C. Asking her to state her name out loud D. Palpating the side of her neck for blood seepage Answer: (C) Asking her to state her name out loud If the recurrent laryngeal nerve is damaged during surgery, the client will be

hoarse and have difficult speaking. 164. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight loss D. Insomnia and excitability Answer: (B) Dry skin and fatigue Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism. 165. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should: A. Elevate the head of my bed at night B. Avoid moving my extra-ocular muscles C. Avoid using a sleeping mask at night D. Avoid excessive blinking Answer: (C) Avoid using a sleeping mask at night The mask may irritate or scratch the eye if the client turns and lies on it during the night. 166. Clara is a 37-year old cook. She is admitted for treatment of partial and fullthickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is: A. 4.5% B. 9% C. 18 % D. 22.5% Answer: (D) 22.5% The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5% 167. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will: A. Inhibit bacterial growth

B. Relieve pain from the burn C. Prevent scar tissue formation D. Provide chemical debridement Answer: (A) Inhibit bacterial growth Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes 168. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: A. 18 gtt/min B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min Answer: (B) 28 gtt/min This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 169. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will: A. Debride necrotic epithelium B. Be sutured in place for better adherence C. Relieve pain and promote rapid epithelialization D. Frequently be used concurrently with topical antimicrobials. Answer: (C) Relieve pain and promote rapid epithelialization The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing. 170. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the: A. Semi-fowler’s position B. Sims’ position C. Orthopneic position D. Supine position Answer: (C) Orthopneic position The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion 171. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement

C. Rapid but brief symptomatic improvement D. Symptomatic improvement of just the ptosis Answer: (C) Rapid but brief symptomatic improvement Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes. 172. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: A. Develop a teaching plan B. Facilitate psychologic adjustment C. Maintain the present muscle strength D. Prepare for the appearance of myasthenic crisis Answer: (C) Maintain the present muscle strength Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy 173. The most significant initial nursing observations that need to be made about a client with myasthenia include: A. Ability to chew and speak distinctly B. Degree of anxiety about her diagnosis C. Ability to smile an to close her eyelids D. Respiratory exchange and ability to swallow Answer: (D) Respiratory exchange and ability to swallow Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration 174. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to: A. Administer the medication exactly on time B. Administer the medication with food or mild C. Evaluate the client’s muscle strength hourly after medication D. Evaluate the client’s emotional side effects between doses Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels. 175. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to: A. Change her diet order from soft foods to clear liquids B. Place an emergency tracheostomy set in her room C. Assess her respiratory status before and after meals D. Coordinate her meal schedule with the peak effect of her medication, Mestinon

Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

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Wednesday, November 19, 2008

Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC)
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check for updates within specific sections you might be interested in because your browser or Feed reader will do this for you automatically on a regular basis plus you can even get email notification. Thank you so much. Enjoy! If you like this post, Digg It! Click on the Digg button. MATERNITY NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB, NurseReview.Org IS NOT RESPONSIBLE FOR ANY TYPOS, WRONG ANSWERS, WRONG RATIONALE, INCONSISTENCIES, ETC.. USE THIS AT YOUR DESGRESSION 1. You performed the leopold’s maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location? A. Left lower quadrant B. Right lower quadrant C. Left upper quadrant D. Right upper quadrant Answer: (B) Right lower quadrant Right lower quadrant. The landmark to look for when looking for PMI is the location of the fetal back in relation to the right or left side of the mother and the presentation, whether cephalic or breech. The best site is the fetal back nearest the head. 2. In Leopold’s maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass. The correct interpretation of this finding is: A. The mass palpated at the fundal part is the head part. B. The presentation is breech. C. The mass palpated is the back D. The mass palpated is the buttocks. Answer: (D) The mass palpated is the buttocks. The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the mass. 3. In Leopold’s maneuver step # 3 you palpated a hard round movable mass at the supra pubic area. The correct interpretation is that the mass palpated is: A. The buttocks because the presentation is breech. B. The mass palpated is the head. C. The mass is the fetal back. D. The mass palpated is the fetal small part Answer: (B) The mass palpated is the head. When the mass palpated is hard round and movable, it is the fetal head. 4. The hormone responsible for a positive pregnancy test is: A. Estrogen B. Progesterone C. Human Chorionic Gonadotropin D. Follicle Stimulating hormone

Answer: (C) Human Chorionic Gonadotropin Human chorionic gonadotropin (HCG) is the hormone secreted by the chorionic villi which is the precursor of the placenta. In the early stage of pregnancy, while the placenta is not yet fully developed, the major hormone that sustains the pregnancy is HCG. 5. The hormone responsible for the maturation of the graafian follicle is: A. Follicle stimulating hormone B. Progesterone C. Estrogen D. Luteinizing hormone Answer: (A) Follicle stimulating hormone The hormone that stimulates the maturation if the of the graafian follicle is the Follicle Stimulating Hormone which is released by the anterior pituitary gland. 7. The most common normal position of the fetus in utero is: A. Transverse position B. Vertical position C. Oblique position D. None of the above Answer: (B) Vertical position Vertical position means the fetal spine is parallel to the maternal spine thus making it easy for the fetus to go out the birth canal. If transverse or oblique, the fetus can’t be delivered normally per vagina. 8. In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as: A. A normal occurrence in pregnancy because the fetus is using more oxygen B. The fundus of the uterus is high pushing the diaphragm upwards C. The woman is having allergic reaction to the pregnancy and its hormones D. The woman maybe experiencing complication of pregnancy Answer: (B) The fundus of the uterus is high pushing the diaphragm upwards From the 32nd week of the pregnancy, the fundus of the enlarged uterus is pushing the respiratory diaphragm upwards. Thus, the lungs have reduced space for expansion consequently reducing the oxygen supply. 9. Which of the following findings in a woman would be consistent with a pregnancy of two months duration? A. Weight gain of 6-10 lbs. and presence of striae gravidarum B. Fullness of the breast and urinary frequency C. Braxton Hicks contractions and quickening D. Increased respiratory rate and ballottement Answer: (B) Fullness of the breast and urinary frequency Fullness of the breast is due to the increased amount of progesterone in pregnancy. The urinary frequency is caused by the compression of the urinary bladder by the gravid uterus which is still within the pelvic cavity during the first trimester.

10. Which of the following is a positive sign of pregnancy? A. Fetal movement felt by mother B. Enlargement of the uterus C. (+) pregnancy test D. (+) ultrasound Answer: (D) (+) ultrasound A positive ultrasound will definitely confirm that a woman is pregnant since the fetus in utero is directly visualized. 11. What event occurring in the second trimester helps the expectant mother to accept the pregnancy? A. Lightening B. Ballotment C. Pseudocyesis D. Quickening Answer: (D) Quickening Quickening is the first fetal movement felt by the mother makes the woman realize that she is truly pregnant. In early pregnancy, the fetus is moving but too weak to be felt by the mother. In the 18th-20th week of gestation, the fetal movements become stronger thus the mother already feels the movements. 12. Shoes with low, broad heels, plus a good posture will prevent which prenatal discomfort? A. Backache B. Vertigo C. Leg cramps D. Nausea Answer: (A) Backache Backache usually occurs in the lumbar area and becomes more problematic as the uterus enlarges. The pregnant woman in her third trimester usually assumes a lordotic posture to maintain balance causing an exaggeration of the lumbar curvature. Low broad heels provide the pregnant woman with a good support. 13. When a pregnant woman experiences leg cramps, the correct nursing intervention to relieve the muscle cramps is: A. Allow the woman to exercise B. Let the woman walk for a while C. Let the woman lie down and dorsiflex the foot towards the knees D. Ask the woman to raise her legs Answer: (C) Let the woman lie down and dorsiflex the foot towards the knees Leg cramps is caused by the contraction of the gastrocnimeus (leg muscle). Thus, the intervention is to stretch the muscle by dosiflexing the foot of the affected leg towards the knee. 14. From the 33rd week of gestation till full term, a healthy mother should have prenatal check up every: A. week B. 2 weeks C. 3 weeks

D. 4 weeks Answer: (A) week In the 9th month of pregnancy the mother needs to have a weekly visit to the prenatal clinic to monitor fetal condition and to ensure that she is adequately prepared for the impending labor and delivery. 15. The expected weight gain in a normal pregnancy during the 3rd trimester is A. 1 pound a week B. 2 pounds a week C. 10 lbs a month D. 10 lbs total weight gain in the 3rd trimester Answer: (A) 1 pound a week During the 3rd trimester the fetus is gaining more subcutaneous fat and is growing fast in preparation for extra uterine life. Thus, one pound a week is expected. 16. In the Batholonew’s rule of 4, when the level of the fundus is midway between the umbilicus and xyphoid process the estimated age of gestation (AOG) is: A. 5th month B. 6th month C. 7th month D. 8th month Answer: (C) 7th month In Bartholomew’s Rule of 4, the landmarks used are the symphysis pubis, umbilicus and xyphoid process. At the level of the umbilicus, the AOG is approximately 5 months and at the level of the xyphoid process 9 months. Thus, midway between these two landmarks would be considered as 7 months AOG. 17. The following are ways of determining expected date of delivery (EDD) when the LMP is unknown EXCEPT: A. Naegele’s rule B. Quickening C. Mc Donald’s rule D. Batholomew’s rule of 4 Answer: (A) Naegele’s rule Naegele’s Rule is determined based on the last menstrual period of the woman. 18. If the LMP is Jan. 30, the expected date of delivery (EDD) is A. Oct. 7 B. Oct. 24 C. Nov. 7 D. Nov. 8 Answer: (C) Nov. 7 Based on the last menstrual period, the expected date of delivery is Nov. 7. The formula for the Naegele’s Rule is subtract 3 from the month and add 7 to the day.

19. Kegel’s exercise is done in pregnancy in order to: A. Strengthen perineal muscles B. Relieve backache C. Strengthen abdominal muscles D. Prevent leg varicosities and edema Answer: (A) Strengthen perineal muscles Kegel’s exercise is done by contracting and relaxing the muscles surrounding the vagina and anus in order to strengthen the perineal muscles 20. Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort? A. Leg cramps B. Urinary frequency C. Orthostatic hypotension D. Backache Answer: (D) Backache Backache is caused by the stretching of the muscles of the lower back because of the pregnancy. Pelvic rocking is good to relieve backache. 21. The main reason for an expected increased need for iron in pregnancy is: A. The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow B. The mother may suffer anemia because of poor appetite C. The fetus has an increased need for RBC which the mother must supply D. The mother may have a problem of digestion because of pica Answer: (A) The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow About 400 mgs of Iron is needed by the mother in order to produce more RBC mass to be able to provide the needed increase in blood supply for the fetus. Also, about 350-400 mgs of iron is need for the normal growth of the fetus. Thus, about 750-800 mgs iron supplementation is needed by the mother to meet this additional requirement. 22. The diet that is appropriate in normal pregnancy should be high in A. Protein, minerals and vitamins B. Carbohydrates and vitamins C. Proteins, carbohydrates and fats D. Fats and minerals Answer: (A) Protein, minerals and vitamins In normal pregnancy there is a higher demand for protein (body building foods), vitamins (esp. vitamin A, B, C, folic acid) and minerals (esp. iron, calcium, phosphorous, zinc, iodine, magnesium) because of the need of the growing fetus. 24. Which of the following signs will require a mother to seek immediate medical attention? A. When the first fetal movement is felt B. No fetal movement is felt on the 6th month C. Mild uterine contraction

D. Slight dyspnea on the last month of gestation Answer: (B) No fetal movement is felt on the 6th month Fetal movement is usually felt by the mother during 4.5 – 5 months. If the pregnancy is already in its 6th month and no fetal movement is felt, the pregnancy is not normal either the fetus is already dead intra-uterine or it is an H-mole. 25. You want to perform a pelvic examination on one of your pregnant clients. You prepare your client for the procedure by: A. Asking her to void B. Taking her vital signs and recording the readings C. Giving the client a perineal care D. Doing a vaginal prep Answer: (A) Asking her to void A pelvic examination includes abdominal palpation. If the pregnant woman has a full bladder, the manipulation may cause discomfort and accidental urination because of the pressure applied during the abdominal palpation. Also, a full bladder can impede the accuracy of the examination because the bladder (which is located in front of the uterus) can block the uterus. 26. When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to: A. Observe NPO from midnight to avoid vomiting B. Do perineal flushing properly before the procedure C. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done D. Void immediately before the procedure for better visualization Answer: (C) Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done Drinking at least 2 liters of water 2 hours before the procedure will result to a distended bladder. A full bladder is needed when doing an abdominal ultrasound to serve as a “window” for the ultrasonic sound waves to pass through and allow visualization of the uterus (located behind the urinary bladder). 27. The nursing intervention to relieve “morning sickness” in a pregnant woman is by giving A. Dry carbohydrate food like crackers B. Low sodium diet C. Intravenous infusion D. Antacid Answer: (A) Dry carbohydrate food like crackers Morning sickness maybe caused by hypoglycemia early in the morning thus giving carbohydrate food will help. 28. The common normal site of nidation/implantation in the uterus is A. Upper uterine portion B. Mid-uterine area C. Lower uterine segment D. Lower cervical segment

Answer: (A) Upper uterine portion The embryo’s normal nidation site is the upper portion of the uterus. If the implantation is in the lower segment, this is an abnormal condition called placenta previa. 29. Mrs. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy and the first pregnancy was a twin. She is considered to be A. G 4 P 3 B. G 5 P 3 C. G 5 P 4 D. G 4 P 4 Answer: (B) G 5 P 3 Gravida refers to the total number of pregnancies including the current one. Para refers to the number of pregnancies that have reached viability. Thus, if the woman has had one abortion, she would be considered Para 3. Twin pregnancy is counted only as 1. 30. The following are skin changes in pregnancy EXCEPT: A. Chloasma B. Striae gravidarum C. Linea negra D. Chadwick's sign Answer: (D) Chadwick's sign Chadwick's sign is bluish discoloration of the vaginal mucosa as a result of the increased vascularization in the area. 31. Which of the following statements is TRUE of conception? A. Within 2-4 hours after intercourse conception is possible in a fertile woman B. Generally, fertilization is possible 4 days after ovulation C. Conception is possible during menstruation in a long menstrual cycle D. To avoid conception, intercourse must be avoided 5 days before and 3 days after menstruation Answer: (A) Within 2-4 hours after intercourse conception is possible in a fertile woman The sperms when deposited near the cervical os will be able to reach the fallopian tubes within 4 hours. If the woman has just ovulated (within 24hours after the rupture of the graafian follicle), fertilization is possible. 32. Which of the following are the functions of amniotic fluid? 1.Cushions the fetus from abdominal trauma 2.Serves as the fluid for the fetus 3.Maintains the internal temperature 4.Facilitates fetal movement A. 1 & 3 B. 1, 3, 4 C. 1, 2, 3 D. All of the above Answer: (D) All of the above All the four functions enumerated are true of amniotic fluid.

33. You are performing abdominal exam on a 9th month pregnant woman. While lying supine, she felt breathless, had pallor, tachycardia, and cold clammy skin. The correct assessment of the woman’s condition is that she is A. Experiencing the beginning of labor B. Having supine hypotension C. Having sudden elevation of BP D. Going into shock Answer: (B) Having supine hypotension Supine hypotension is characterized by breathlessness, pallor, tachycardia and cold clammy skin. This is due to the compression of the abdominal aorta by the gravid uterus when the woman is on a supine position. 34. Smoking is contraindicated in pregnancy because A. Nicotine causes vasodilation of the mother’s blood vessels B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus C. The smoke will make the fetus and the mother feel dizzy D. Nicotine will cause vasoconstriction of the fetal blood vessels Answer: (B) Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus Carbon monoxide is one of the substances found in cigarette smoke. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus. 35. Which of the following is the most likely effect on the fetus if the woman is severely anemic during pregnancy? A. Large for gestational age (LGA) fetus B. Hemorrhage C. Small for gestational age (SGA) baby D. Erythroblastosis fetalis Answer: (C) Small for gestational age (SGA) baby Anemia is a condition where there is a reduced amount of hemoglobin. Hemoglobin is needed to supply the fetus with adequate oxygen. Oxygen is needed for normal growth and development of the fetus. 36. Which of the following signs and symptoms will most likely make the nurse suspect that the patient is having hydatidiform mole? A. Slight bleeding B. Passage of clear vesicular mass per vagina C. Absence of fetal heart beat D. Enlargement of the uterus Answer: (B) Passage of clear vesicular mass per vagina Hydatidiform mole (H-mole) is characterized by the degeneration of the chorionic villi wherein the villi becomes vesicle-like. These vesicle-like substances when expelled per vagina and is a definite sign that the woman has H-mole. 37. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat

(FHB) not appreciated. Which of the following is the most possible diagnosis of this condition? A. Hydatidiform mole B. Missed abortion C. Pelvic inflammatory disease D. Ectopic pregnancy Answer: (A) Hydatidiform mole Hydatidiform mole begins as a pregnancy but early in the development of the embryo degeneration occurs. The proliferation of the vesicle-like substances is rapid causing the uterus to enlarge bigger than the expected size based on ages of gestation (AOG). In the situation given, the pregnancy is only 5 months but the size of the uterus is already above the umbilicus which is compatible with 7 months AOG. Also, no fetal heart beat is appreciated because the pregnancy degenerated thus there is no appreciable fetal heart beat. 38. When a pregnant woman goes into a convulsive seizure, the MOST immediate action of the nurse to ensure safety of the patient is: A. Apply restraint so that the patient will not fall out of bed B. Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back C. Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration D. Check if the woman is also having a precipitate labor Answer: (C) Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration Positioning the mother on her side will allow the secretions that may accumulate in her mouth to drain by gravity thus preventing aspiration pneumonia. Putting a mouth gag is not safe since during the convulsive seizure the jaw will immediately lock. The mother may go into labor also during the seizure but the immediate concern of the nurse is the safety of the baby. After the seizure, check the perineum for signs of precipitate labor. 39. A gravido-cardiac mother is advised to observe bedrest primarily to A. Allow the fetus to achieve normal intrauterine growth B. Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother C. Prevent perinatal infection D. Reduce incidence of premature labor Answer: (B) Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother Activity of the mother will require more oxygen consumption. Since the heart of a gravido-cardiac is compromised, there is a need to put a mother on bedrest to reduce the need for oxygen. 40. A pregnant mother is admitted to the hospital with the chief complaint of profuse vaginal bleeding, AOG 36 wks, not in labor. The nurse must always consider which of the following precautions: A. The internal exam is done only at the delivery under strict asepsis with a double set-up B. The preferred manner of delivering the baby is vaginal C. An emergency delivery set for vaginal delivery must be made ready before examining the patient D. Internal exam must be done following routine procedure

Answer: (A) The internal exam is done only at the delivery under strict asepsis with a double set-up Painless vaginal bleeding during the third trimester maybe a sign of placenta praevia. If internal examination is done in this kind of condition, this can lead to even more bleeding and may require immediate delivery of the baby by cesarean section. If the bleeding is due to soft tissue injury in the birth canal, immediate vaginal delivery may still be possible so the set up for vaginal delivery will be used. A double set-up means there is a set up for cesarean section and a set-up for vaginal delivery to accommodate immediately the necessary type of delivery needed. In both cases, strict asepsis must be observed. 41. Which of the following signs will distinguish threatened abortion from imminent abortion? A. Severity of bleeding B. Dilation of the cervix C. Nature and location of pain D. Presence of uterine contraction Answer: (B) Dilation of the cervix In imminent abortion, the pregnancy will definitely be terminated because the cervix is already open unlike in threatened abortion where the cervix is still closed. 42. The nursing measure to relieve fetal distress due to maternal supine hypotension is: A. Place the mother on semi-fowler’s position B. Put the mother on left side lying position C. Place mother on a knee chest position D. Any of the above Answer: (B) Put the mother on left side lying position When a pregnant woman lies on supine position, the weight of the gravid uterus would be compressing on the vena cava against the vertebrae obstructing blood flow from the lower extremities. This causes a decrease in blood return to the heart and consequently immediate decreased cardiac output and hypotension. Hence, putting the mother on side lying will relieve the pressure exerted by the gravid uterus on the vena cava. 43. To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drugs commonly given are: A. Magnesium sulfate and terbutaline B. Prostaglandin and oxytocin C. Progesterone and estrogen D. Dexamethasone and prostaglandin Answer: (A) Magnesium sulfate and terbutaline Magnesium sulfate acts as a CNS depressant as well as a smooth muscle relaxant. Terbutaline is a drug that inhibits the uterine smooth muscles from contracting. On the other hand, oxytocin and prostaglandin stimulates contraction of smooth muscles. 44. In placenta praevia marginalis, the placenta is found at the:

A. Internal cervical os partly covering the opening B. External cervical os slightly covering the opening C. Lower segment of the uterus with the edges near the internal cervical os D. Lower portion of the uterus completely covering the cervix Answer: (C) Lower segment of the uterus with the edges near the internal cervical os Placenta marginalis is a type of placenta previa wherein the placenta is implanted at the lower segment of the uterus thus the edges of the placenta are touching the internal cervical opening/os. The normal site of placental implantation is the upper portion of the uterus. 45. In which of the following conditions can the causative agent pass through the placenta and affect the fetus in utero? A. Gonorrhea B. Rubella C. Candidiasis D. moniliasis Answer: (B) Rubella Rubella is caused by a virus and viruses have low molecular weight thus can pass through the placental barrier. Gonorrhea, candidiasis and moniliasis are conditions that can affect the fetus as it passes through the vaginal canal during the delivery process. 46. Which of the following can lead to infertility in adult males? A. German measles B. Orchitis C. Chicken pox D. Rubella Answer: (B) Orchitis Orchitis is a complication that may accompany mumps in adult males. This condition is characterized by unilateral inflammation of one of the testes which can lead to atrophy of the affected testis. About 20-30% of males who gets mumps after puberty may develop this complication. 47. Papanicolaou smear is usually done to determine cancer of A. Cervix B. Ovaries C. Fallopian tubes D. Breast Answer: (A) Cervix Papanicolaou (Paps) smear is done to detect cervical cancer. It can’t detect cancer in ovaries and fallopian tubes because these organs are outside of the uterus and the abnormal cells from these organs will not be detected from a smear done on the cervix. 48. Which of the following causes of infertility in the female is primarily psychological in origin? A. Vaginismus B. Dyspareunia

C. Endometriosis D. Impotence Answer: (A) Vaginismus Vaginismus is primarily psychological in origin. Endometriosis is a condition that is caused by organic abnormalities. Dyspareunia is usually caused by infection, endometriosis or hormonal changes in menopause although may sometimes be psychological in origin. 49. Before giving a repeat dose of magnesium sulfate to a pre-eclamptic patient, the nurse should assess the patient’s condition. Which of the following conditions will require the nurse to temporarily suspend a repeat dose of magnesium sulfate? A. 100 cc. urine output in 4 hours B. Knee jerk reflex is (+)2 C. Serum magnesium level is 10mEg/L. D. Respiratory rate of 16/min Answer: (A) 100 cc. urine output in 4 hours The minimum urine output expected for a repeat dose of MgSO4 is 30 cc/hr. If in 4 hours the urine output is only 100 cc this is low and can lead to poor excretion of Magnesium with a possible cumulative effect, which can be dangerous to the mother. 50. Which of the following is TRUE in Rh incompatibility? A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-) B. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected D. RhoGam is given only during the first pregnancy to prevent incompatibility Answer: (C) On the first pregnancy of the Rh(-) mother, the fetus will not be affected On the first pregnancy, the mother still has no contact with Rh(+) blood thus it has not antibodies against Rh(+). After the first pregnancy, even if terminated into an abortion, there is already the possibility of mixing of maternal and fetal blood so this can trigger the maternal blood to produce antibodies against Rh(+) blood. The fetus takes it’s blood type usually form the father. 51. Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus? A. Diabetes in the mother B. Maternal cardiac condition C. Premature labor D. Abruptio placenta Answer: (B) Maternal cardiac condition In general, when the heart is compromised such as in maternal cardiac condition, the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. Thus if the blood supply is less, the baby will suffer from chronic hypoxia leading to a small-for-gestational age condition. 52. The lower limit of viability for infants in terms of age of gestation is:

A. 21-24 weeks B. 25-27 weeks C. 28-30 weeks D. 38-40 weeks Answer: (A) 21-24 weeks Viability means the capability of the fetus to live/survive outside of the uterine environment. With the present technological and medical advances, 21 weeks AOG is considered as the minimum fetal age for viability. 53. Which provision of our 1987 constitution guarantees the right of the unborn child to life from conception is A. Article II section 12 B. Article II section 15 C. Article XIII section 11 D. Article XIII section 15 Answer: (A) Article II section 12 The Philippine Constitution of 1987 guarantees the right of the unborn child from conception equal to the mother as stated in Article II State Policies, Section 12. 54. In the Philippines, if a nurse performs abortion on the mother who wants it done and she gets paid for doing it, she will be held liable because A. Abortion is immoral and is prohibited by the church B. Abortion is both immoral and illegal in our country C. Abortion is considered illegal because you got paid for doing it D. Abortion is illegal because majority in our country are catholics and it is prohibited by the church Answer: (B) Abortion is both immoral and illegal in our country Induced Abortion is illegal in the country as stated in our Penal Code and any person who performs the act for a fee commits a grave offense punishable by 1012 years of imprisonment. The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesia. The main rationale for this is: A. To allow atraumatic delivery of the baby B. To allow a gradual shifting of the blood into the maternal circulation C. To make the delivery effort free and the mother does not need to push with contractions D. To prevent perineal laceration with the expulsion of the fetal head Answer: (C) To make the delivery effort free and the mother does not need to push with contractions Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. Pushing requires more effort which a compromised heart may not be able to endure. 56. When giving narcotic analgesics to mother in labor, the special consideration to follow is: A. The progress of labor is well established reaching the transitional stage B. Uterine contraction is progressing well and delivery of the baby is imminent C. Cervical dilatation has already reached at least 8 cm. and the station is at least

(+)2 D. Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Answer: (D) Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. Also, it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier. 57. The cervical dilatation taken at 8:00 A.M. in a G1P0 patient was 6 cm. A repeat I.E. done at 10 A.M. showed that cervical dilation was 7 cm. The correct interpretation of this result is: A. Labor is progressing as expected B. The latent phase of Stage 1 is prolonged C. The active phase of Stage 1 is protracted D. The duration of labor is normal Answer: (C) The active phase of Stage 1 is protracted The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protracted. 58. Which of the following techniques during labor and delivery can lead to uterine inversion? A. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation C. Massaging the fundus to encourage the uterus to contract D. Applying light traction when delivering the placenta that has already detached from the uterine wall Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached. 59. The fetal heart rate is checked following rupture of the bag of waters in order to: A. Check if the fetus is suffering from head compression B. Determine if cord compression followed the rupture C. Determine if there is utero-placental insufficiency D. Check if fetal presenting part has adequately descended following the rupture Answer: (B) Determine if cord compression followed the rupture After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the rupture and flow. If the cord goes out of the cervical opening, before the head is delivered (cephalic presentation), the head

can compress on the cord causing fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. 60. Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours post partum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing diagnosis is: A. Normal blood loss B. Blood volume deficiency C. Inadequate tissue perfusion related to hemorrhage D. Hemorrhage secondary to uterine atony Answer: (D) Hemorrhage secondary to uterine atony All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boundaries not well defined, the cause of the hemorrhage could be uterine atony. 61. The following are signs and symptoms of fetal distress EXCEPT: A. Fetal heart rate (FHR) decreased during a contraction and persists even after the uterine contraction ends B. The FHR is less than 120 bpm or over 160 bpm C. The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm D. FHR is 160 bpm, weak and irregular Answer: (C) The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usually goes down but must return to its pre-contraction rate after the contraction ends. 62. If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may occur: 1.Laceration of cervix 2.Laceration of perineum 3.Cranial hematoma in the fetus 4.Fetal anoxia A. 1 & 2 B. 2 & 4 C. 2,3,4 D. 1,2,3,4 Answer: (D) 1,2,3,4 all the above conditions can occur following a precipitate labor and delivery of the fetus because there was little time for the baby to adapt to the passageway. If the presentation is cephalic, the fetal head serves as the main part of the fetus that pushes through the birth canal which can lead to cranial hematoma, and possible compression of cord may occur which can lead to less blood and oxygen to the fetus (hypoxia). Likewise the maternal passageway (cervix, vaginal canal and perineum) did not have enough time to stretch which can lead to laceration. 63. The primary power involved in labor and delivery is

A. Bearing down ability of mother B. Cervical effacement and dilatation C. Uterine contraction D. Valsalva technique Answer: (C) Uterine contraction Uterine contraction is the primary force that will expel the fetus out through the birth canal Maternal bearing down is considered the secondary power/force that will help push the fetus out. 64. The proper technique to monitor the intensity of a uterine contraction is A. Place the palm of the hands on the abdomen and time the contraction B. Place the finger tips lightly on the suprapubic area and time the contraction C. Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction D. Put the palm of the hands on the fundal area and feel the contraction at the fundal area Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction In monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. The fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand. 65. To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction A. From the beginning of one contraction to the end of the same contraction B. From the beginning of one contraction to the beginning of the next contraction C. From the end of one contraction to the beginning of the next contraction D. From the deceleration of one contraction to the acme of the next contraction Answer: (B) From the beginning of one contraction to the beginning of the next contraction Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction. 66. The peak point of a uterine contraction is called the A. Acceleration B. Acme C. Deceleration D. Axiom Answer: (B) Acme Acme is the technical term for the highest point of intensity of a uterine contraction. 67. When determining the duration of a uterine contraction the right technique is to time it from A. The beginning of one contraction to the end of the same contraction B. The end of one contraction to the beginning of another contraction C. The acme point of one contraction to the acme point of another contraction D. The beginning of one contraction to the end of another contraction

Answer: (A) The beginning of one contraction to the end of the same contraction Duration of a uterine contraction refers to one contraction. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction. 68. When the bag of waters ruptures, the nurse should check the characteristic of the amniotic fluid. The normal color of amniotic fluid is A. Clear as water B. Bluish C. Greenish D. Yellowish Answer: (A) Clear as water The normal color of amniotic fluid is clear like water. If it is yellowish, there is probably Rh incompatibility. If the color is greenish, it is probably meconium stained. 69. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is: A. Push back the prolapse cord into the vaginal canal B. Place the mother on semifowler’s position to improve circulation C. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position D. Push back the cord into the vagina and place the woman on sims position Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. Observe strict asepsis in the care of the cord to prevent infection. The cord has to be kept moist to prevent it from drying. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on trendellenberg or sims position 70. The fetal heart beat should be monitored every 15 minutes during the 2nd stage of labor. The characteristic of a normal fetal heart rate is A. The heart rate will decelerate during a contraction and then go back to its precontraction rate after the contraction B. The heart rate will accelerate during a contraction and remain slightly above the pre-contraction rate at the end of the contraction C. The rate should not be affected by the uterine contraction. D. The heart rate will decelerate at the middle of a contraction and remain so for about a minute after the contraction Answer: (A) The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction The normal fetal heart rate will decelerate (go down) slightly during a contraction because of the compression on the fetal head. However, the heart rate should go back to the pre-contraction rate as soon as the contraction is over since the compression on the head has also ended. 71. The mechanisms involved in fetal delivery is A. Descent, extension, flexion, external rotation

B. Descent, flexion, internal rotation, extension, external rotation C. Flexion, internal rotation, external rotation, extension D. Internal rotation, extension, external rotation, flexion Answer: (B) Descent, flexion, internal rotation, extension, external rotation The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. Flexion, internal rotation and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus. 72. The first thing that a nurse must ensure when the baby’s head comes out is A. The cord is intact B. No part of the cord is encircling the baby’s neck C. The cord is still attached to the placenta D. The cord is still pulsating Answer: (B) No part of the cord is encircling the baby’s neck The nurse should check right away for possible cord coil around the neck because if it is present, the baby can be strangulated by it and the fetal head will have difficulty being delivered. 73. To ensure that the baby will breath as soon as the head is delivered, the nurse’s priority action is to A. Suction the nose and mouth to remove mucous secretions B. Slap the baby’s buttocks to make the baby cry C. Clamp the cord about 6 inches from the base D. Check the baby’s color to make sure it is not cyanotic Answer: (A) Suction the nose and mouth to remove mucous secretions Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.) 74. When doing perineal care in preparation for delivery, the nurse should observe the following EXCEPT A. Use up-down technique with one stroke B. Clean from the mons veneris to the anus C. Use mild soap and warm water D. Paint the inner thighs going towards the perineal area Answer: (D) Paint the inner thighs going towards the perineal area Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. The perineal area is the one being prepared for the delivery and must be kept clean 75. What are the important considerations that the nurse must remember after the placenta is delivered? 1.Check if the placenta is complete including the membranes

2.Check if the cord is long enough for the baby 3.Check if the umbilical cord has 3 blood vessels 4.Check if the cord has a meaty portion and a shiny portion A. 1 and 3 B. 2 and 4 C. 1, 3, and 4 D. 2 and 3 Answer: (A) 1 and 3 The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. Also, the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels, 2 veins and 1 artery. 76. The following are correct statements about false labor EXCEPT A. The pain is irregular in intensity and frequency. B. The duration of contraction progressively lengthens over time C. There is no vaginal bloody discharge D. The cervix is still closed. Answer: (B) The duration of contraction progressively lengthens over time In false labor, the contractions remain to be irregular in intensity and duration while in true labor, the contractions become stronger, longer and more frequent. 77. The passageway in labor and deliver of the fetus include the following EXCEPT A. Distensibility of lower uterine segment B. Cervical dilatation and effacement C. Distensibility of vaginal canal and introitus D. Flexibility of the pelvis Answer: (D) Flexibility of the pelvis The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus. 78. The normal umbilical cord is composed of: A. 2 arteries and 1 vein B. 2 veins and 1 artery C. 2 arteries and 2 veins D. none of the above Answer: (A) 2 arteries and 1 vein the umbilical cord is composed of 2 arteries and 1 vein. 79. At what stage of labor and delivery does a primigravida differ mainly from a multigravida? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Answer: (A) Stage 1 In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor. 80. The second stage of labor begins with ___ and ends with __? A. Begins with full dilatation of cervix and ends with delivery of placenta B. Begins with true labor pains and ends with delivery of baby C. Begins with complete dilatation and effacement of cervix and ends with delivery of baby D. Begins with passage of show and ends with full dilatation and effacement of cervix Answer: (C) Begins with complete dilatation and effacement of cervix and ends with delivery of baby Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix. 81. The following are signs that the placenta has detached EXCEPT: A. Lengthening of the cord B. Uterus becomes more globular C. Sudden gush of blood D. Mother feels like bearing down Answer: (D) Mother feels like bearing down Placental detachment does not require the mother to bear down. A normal placenta will detach by itself without any effort from the mother. 82. When the shiny portion of the placenta comes out first, this is called the ___ mechanism. A. Schultze B. Ritgens C. Duncan D. Marmets Answer: (A) Schultze There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes out first, it is called the Schultze mechanism; while if the meaty portion comes out first, it is called the Duncan mechanism. 83. When the baby’s head is out, the immediate action of the nurse is A. Cut the umbilical cord B. Wipe the baby’s face and suction mouth first C. Check if there is cord coiled around the neck D. Deliver the anterior shoulder Answer: (C) Check if there is cord coiled around the neck The nurse should check if there is a cord coil because the baby will not be delivered safely if the cord is coiled around its neck. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a “nasal obligate” breather. If the nose is suctioned first before the mouth, the mucus plugging the

mouth can be aspirated by the baby. 84. When delivering the baby’s head the nurse supports the mother’s perineum to prevent tear. This technique is called A. Marmet’s technique B. Ritgen’s technique C. Duncan maneuver D. Schultze maneuver Answer: (B) Ritgen’s technique Ritgen’s technique is done to prevent perineal tear. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby’s head as it goes out of the vaginal opening. 85. The basic delivery set for normal vaginal delivery includes the following instruments/articles EXCEPT: A. 2 clamps B. Pair of scissors C. Kidney basin D. Retractor Answer: (D) Retractor For normal vaginal delivery, the nurse needs only the instruments for cutting the umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the kidney basin to receive the placenta. The retractor is not part of the basic set. In the hospital setting, needle holder and tissue forceps are added especially if the woman delivering the baby is a primigravida wherein episiotomy is generally done. 86. As soon as the placenta is delivered, the nurse must do which of the following actions? A. Inspect the placenta for completeness including the membranes B. Place the placenta in a receptacle for disposal C. Label the placenta properly D. Leave the placenta in the kidney basin for the nursing aide to dispose properly Answer: (A) Inspect the placenta for completeness including the membranes The placenta must be inspected for completeness to include the membranes because an incomplete placenta could mean that there is retention of placental fragments which can lead to uterine atony. If the uterus does not contract adequately, hemorrhage can occur. 87. In vaginal delivery done in the hospital setting, the doctor routinely orders an oxytocin to be given to the mother parenterally. The oxytocin is usually given after the placenta has been delivered and not before because: A. Oxytocin will prevent bleeding B. Oxytocin can make the cervix close and thus trap the placenta inside C. Oxytocin will facilitate placental delivery D. Giving oxytocin will ensure complete delivery of the placenta Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside

The action of oxytocin is to make the uterus contract as well make the cervix close. If it is given prior to placental delivery, the placenta will be trapped inside because the action of the drug is almost immediate if given parentally. 88. In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and delivery) particularly in a cesarean section is a critical period because at this stage A. There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. B. The maternal heart is already weak and the mother can die C. The delivery process is strenuous to the mother D. The mother is tired and weak which can distress the heart Answer: (A) There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. During the pregnancy, there is an increase in maternal blood volume to accommodate the need of the fetus. When the baby and placenta have been delivered, there is a fluid shift back to the maternal circulation as part of physiologic adaptation during the postpartum period. In cesarean section, the fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving it less time for the fluid shift to gradually occur. 89. The drug usually given parentally to enhance uterine contraction is: A. Terbutalline B. Pitocin C. Magnesium sulfate D. Lidocaine Answer: (B) Pitocin The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug given to induce labor. 90. The partograph is a tool used to monitor labor. The maternal parameters measured/monitored are the following EXCEPT: A. Vital signs B. Fluid intake and output C. Uterine contraction D. Cervical dilatation Answer: (B) Fluid intake and output Partograph is a monitoring tool designed by the World Health Organization for use by health workers when attending to mothers in labor especially the high risk ones. For maternal parameters all of the above is placed in the partograph except the fluid intake since this is placed in a separate monitoring sheet. 91. The following are natural childbirth procedures EXCEPT: A. Lamaze method B. Dick-Read method C. Ritgen’s maneuver D. Psychoprophylactic method Answer: (C) Ritgen’s maneuver Ritgen’s method is used to prevent perineal tear/laceration during the delivery of

the fetal head. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain. 92. The following are common causes of dysfunctional labor. Which of these can a nurse, on her own manage? A. Pelvic bone contraction B. Full bladder C. Extension rather than flexion of the head D. Cervical rigidity Answer: (B) Full bladder Full bladder can impede the descent of the fetal head. The nurse can readily manage this problem by doing a simple catheterization of the mother. 93. At what stage of labor is the mother is advised to bear down? A. When the mother feels the pressure at the rectal area B. During a uterine contraction C. In between uterine contraction to prevent uterine rupture D. Anytime the mother feels like bearing down Answer: (B) During a uterine contraction The primary power of labor and delivery is the uterine contraction. This should be augmented by the mother’s bearing down during a contraction. 94. The normal dilatation of the cervix during the first stage of labor in a nullipara is A. 1.2 cm./hr B. 1.5 cm./hr. C. 1.8 cm./hr D. 2.0 cm./hr Answer: (A) 1.2 cm./hr For nullipara the normal cervical dilatation should be 1.2 cm/hr. If it is less than that, it is considered a protracted active phase of the first stage. For multipara, the normal cervical dilatation is 1.5 cm/hr. 95. When the fetal head is at the level of the ischial spine, it is said that the station of the head is A. Station –1 B. Station “0” C. Station +1 D. Station +2 Answer: (B) Station “0” Station is defined as the relationship of the fetal head and the level of the ischial spine. At the level of the ischial spine, the station is “0”. Above the ischial spine it is considered (-) station and below the ischial spine it is (+) station. 96. During an internal examination, the nurse palpated the posterior fontanel to be at the left side of the mother at the upper quadrant. The interpretation is that the position of the fetus is: A. LOA B. ROP

C. LOP D. ROA Answer: (A) LOA The landmark used in determine fetal position is the posterior fontanel because this is the nearest to the occiput. So if the nurse palpated the occiput (O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal position is LOA. 97. The following are types of breech presentation EXCEPT: A. Footling B. Frank C. Complete D. Incomplete Answer: (D) Incomplete Breech presentation means the buttocks of the fetus is the presenting part. If it is only the foot/feet, it is considered footling. If only the buttocks, it is frank breech. If both the feet and the buttocks are presenting it is called complete breech. 98. When the nurse palpates the suprapubic area of the mother and found that the presenting part is still movable, the right term for this observation that the fetus is A. Engaged B. Descended C. Floating D. Internal Rotation Answer: (C) Floating The term floating means the fetal presenting part has not entered/descended into the pelvic inlet. If the fetal head has entered the pelvic inlet, it is said to be engaged. 99. The placenta should be delivered normally within ___ minutes after the delivery of the baby. A. 5 minutes B. 30 minutes C. 45 minutes D. 60 minutes Answer: (B) 30 minutes The placenta is delivered within 30 minutes from the delivery of the baby. If it takes longer, probably the placenta is abnormally adherent and there is a need to refer already to the obstetrician. 100. When shaving a woman in preparation for cesarean section, the area to be shaved should be from ___ to ___ A. Under breast to mid-thigh including the pubic area B. The umbilicus to the mid-thigh C. Xyphoid process to the pubic area D. Above the umbilicus to the pubic area Answer: (A) Under breast to mid-thigh including the pubic area Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery, cesarean section. The pubic hair is

definitely to be included in the shaving 101. Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day. A. 1.0 cm B. 2.0 cm C. 2.5 cm D. 3.0 cm Answer: (A) 1.0 cm The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery. 102. The lochia on the first few days after delivery is characterized as A. Pinkish with some blood clots B. Whitish with some mucus C. Reddish with some mucus D. Serous with some brown tinged mucus Answer: (C) Reddish with some mucus Right after delivery, the vaginal discharge called lochia will be reddish because there is some blood, endometrial tissue and mucus. Since it is not pure blood it is non-clotting. 103. Lochia normally disappears after how many days postpartum? A. 5 days B. 7-10 days C. 18-21 days D. 28-30 days Answer: (B) 7-10 days Normally, lochia disappears after 10 days postpartum. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday. 104. After an Rh(-) mother has delivered her Rh (+) baby, the mother is given RhoGam. This is done in order to: A. Prevent the recurrence of Rh(+) baby in future pregnancies B. Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby C. Ensure that future pregnancies will not lead to maternal illness D. To prevent the newborn from having problems of incompatibility when it breastfeeds Answer: (B) Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby In Rh incompatibility, an Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. Giving her RhoGam right after birth will

prevent her immune system from being permanently sensitized to Rh antigen. 105. To enhance milk production, a lactating mother must do the following interventions EXCEPT: A. Increase fluid intake including milk B. Eat foods that increases lactation which are called galactagues C. Exercise adequately like aerobics D. Have adequate nutrition and rest Answer: (C) Exercise adequately like aerobics All the above nursing measures are needed to ensure that the mother is in a healthy state. However, aerobics does not necessarily enhance lactation. 106. The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is A. Apply cold compress on the engorged breast B. Apply warm compress on the engorged breast C. Massage the breast D. Apply analgesic ointment Answer: (B) Apply warm compress on the engorged breast Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to relieve pain as well as suppress lactation, the compress applied is cold. 107. A woman who delivered normally per vagina is expected to void within ___ hours after delivery. A. 3 hrs B. 4 hrs. C. 6-8 hrs D. 12-24 hours Answer: (C) 6-8 hrs A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours, the nurse should stimulate the woman to void. If nursing interventions to stimulate spontaneous voiding don’t work, the nurse may decide to catheterize the woman. 108. To ensure adequate lactation the nurse should teach the mother to: A. Breast feed the baby on self-demand day and night B. Feed primarily during the day and allow the baby to sleep through the night C. Feed the baby every 3-4 hours following a strict schedule D. Breastfeed when the breast are engorged to ensure adequate supply Answer: (A) Breast feed the baby on self-demand day and night Feeding on self-demand means the mother feeds the baby according to baby’s need. Therefore, this means there will be regular emptying of the breasts, which is essential to maintain adequate lactation. 109. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is: A. Encourage the mother to ambulate to relieve the pain in the leg B. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve venous return flow C. Apply warm compress on the affected leg to relieve the pain D. Elevate the affected leg and keep the patient on bedrest

Answer: (D) Elevate the affected leg and keep the patient on bedrest If the mother already has thrombophlebitis, the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation. 110. The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally if this condition was present during the delivery: A. Excessive analgesia was given to the mother B. Placental delivery occurred within thirty minutes after the baby was born C. An episiotomy had to be done to facilitate delivery of the head D. The labor and delivery lasted for 12 hours Answer: (A) Excessive analgesia was given to the mother Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus. 111. According to Rubin’s theory of maternal role adaptation, the mother will go through 3 stages during the post partum period. These stages are: A. Going through, adjustment period, adaptation period B. Taking-in, taking-hold and letting-go C. Attachment phase, adjustment phase, adaptation phase D. Taking-hold, letting-go, attachment phase Answer: (B) Taking-in, taking-hold and letting-go Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in, taking-hold and letting-go. In the taking-in stage, the mother is more passive and dependent on others for care. In taking-hold, the mother begins to assume a more active role in the care of the child and in lettinggo, the mother has become adapted to her maternal role. 112. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because: A. The pancreas is immature and unable to secrete the needed insulin B. There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin C. The baby is reacting to the insulin given to the mother D. His kidneys are immature leading to a high tolerance for glucose Answer: (B) There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother, it no longer receives a high dose of glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can lead to hypoglycemia. 113. Which of the following is an abnormal vital sign in postpartum? A. Pulse rate between 50-60/min B. BP diastolic increase from 80 to 95mm Hg C. BP systolic between 100-120mm Hg D. Respiratory rate of 16-20/min

Answer: (B) BP diastolic increase from 80 to 95mm Hg All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy. 114. The uterine fundus right after delivery of placenta is palpable at A. Level of Xyphoid process B. Level of umbilicus C. Level of symphysis pubis D. Midway between umbilicus and symphysis pubis Answer: (B) Level of umbilicus Immediately after the delivery of the placenta, the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it becomes no longer palpable above the symphysis pubis. 115. After how many weeks after delivery should a woman have her postpartal check-up based on the protocol followed by the DOH? A. 2 weeks B. 3 weeks C. 6 weeks D. 12 weeks Answer: (C) 6 weeks According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to make sure complete involution of the reproductive organs has be achieved. 116. In a woman who is not breastfeeding, menstruation usually occurs after how many weeks? A. 2-4 weeks B. 6-8 weeks C. 6 months D. 12 months Answer: (B) 6-8 weeks When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery, the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Folicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a graafian follicle and the menstrual cycle post pregnancy resumes. 117. The following are nursing measures to stimulate lactation EXCEPT A. Frequent regular breast feeding B. Breast pumping C. Breast massage D. Application of cold compress on the breast Answer: (D) Application of cold compress on the breast To stimulate lactation, warm compress is applied on the breast. Cold application will cause vasoconstriction thus reducing the blood supply consequently the

production of milk. 118. When the uterus is firm and contracted after deli very but there is vaginal bleeding, the nurse should suspect A. Laceration of soft tissues of the cervix and vagina B. Uterine atony C. Uterine inversion D. Uterine hypercontractility Answer: (A) Laceration of soft tissues of the cervix and vagina When uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina. 119. The following are interventions to make the fundus contract postpartally EXCEPT A. Make the baby suck the breast regularly B. Apply ice cap on fundus C. Massage the fundus vigorously for 15 minutes until contracted D. Give oxytocin as ordered Answer: (C) Massage the fundus vigorously for 15 minutes until contracted Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feel firm and contracted. If massaging is vigorous and prolonged, the uterus will relax due to over stimulation. 120. The following are nursing interventions to relieve episiotomy wound pain EXCEPT A. Giving analgesic as ordered B. Sitz bath C. Perineal heat D. Perineal care Answer: (D) Perineal care Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not. 121. Postpartum blues is said to be normal provided that the following characteristics are present. These are 1. Within 3-10 days only; 2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor appetite; 3. Maybe more severe symptoms in primpara A. All of the above B. 1 and 2 C. 2 only D. 2 and 3 Answer: (A) All of the above All the symptoms 1-3 are characteristic of postpartal blues. It will resolve by itself because it is transient and is due to a number of reasons like changes in hormonal levels and adjustment to motherhood. If symptoms lasts more than 2

weeks, this could be a sign of abnormality like postpartum depression and needs treatment. 122. The neonatal circulation differs from the fetal circulation because A. The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. B. The blood at the left atrium of the fetal heart is shunted to the right atrium to facilitate its passage to the lungs C. The blood in left side of the fetal heart contains oxygenated blood while the blood in the right side contains unoxygenated blood. D. None of the above Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. The fetal lungs is fluid-filled while in utero and is still not functioning. It only begins to function in extra uterine life. Except for the blood as it enters the fetus immediately from the placenta, most of the fetal blood is mixed blood. 123. The normal respiration of a newborn immediately after birth is characterized as: A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing D. 30-50 breaths per minute, active use of abdominal and intercostal muscles Answer: (A) Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 breaths per minute A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to function as a respiratory organ. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal. 124. The anterior fontanelle is characterized as: A. 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape B. 2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape C. 2-3 cm in both antero-posterior and transverse diameter and diamond shape D. none of the above Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape The anterior fontanelle is diamond shape with the antero-posterior diameter being longer than the transverse diameter. The posterior fontanelle is triangular shape. 125. The ideal site for vitamin K injection in the newborn is: A. Right upper arm B. Left upper arm

C. Either right or left buttocks D. Middle third of the thigh Answer: (D) Middle third of the thigh Neonates do not have well developed muscles of the arm. Since Vitamin K is given intramuscular, the site must have sufficient muscles like the middle third of the thigh. 126. At what APGAR score at 5 minutes after birth should resuscitation be initiated? A. 1-3 B. 7-8 C. 9-10 D. 6-7 Answer: (A) 1-3 An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10. 127. Right after birth, when the skin of the baby’s trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called: A. Syndactyly B. Acrocyanosis C. Peripheral cyanosis D. Cephalo-caudal cyanosis Answer: (B) Acrocyanosis Acrocyanosis is the term used to describe the baby’s skin color at birth when the soles and palms are bluish but the trunk is pinkish. 128. The minimum birth weight for full term babies to be considered normal is: A. 2,000gms B. 1,500gms C. 2,500gms D. 3,000gms Answer: (C) 2,500gms According to the WHO standard, the minimum normal birth weight of a full term baby is 2,500 gms or 2.5 Kg. 129. The procedure done to prevent ophthalmia neonatorum is: A. Marmet’s technique B. Crede’s method C. Ritgen’s method D. Ophthalmic wash Answer: (B) Crede’s method Crede’s method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acquire as it passes through the birth canal of the mother. Usually, an ophthalmic ointment is used. 130. Which of the following characteristics will distinguish a postmature neonate

at birth? A. Plenty of lanugo and vernix caseosa B. Lanugo mainly on the shoulders and vernix in the skin folds C. Pinkish skin with good turgor D. Almost leather-like, dry, cracked skin, negligible vernix caseosa Answer: (D) Almost leather-like, dry, cracked skin, negligible vernix caseosa A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished. 131. According to the Philippine Nursing Law, a registered nurse is allowed to handle mothers in labor and delivery with the following considerations: 1. The pregnancy is normal.; 2. The labor and delivery is uncomplicated; 3. Suturing of perineal laceration is allowed provided the nurse had special training; 4. As a delivery room nurse she is not allowed to insert intravenous fluid unless she had special training for it. A. 1 and 2 B. 1, 2, and 3 C. 3 and 4 D. 1, 2, and 4 Answer: (B) 1, 2, and 3 To be allowed to handle deliveries, the pregnancy must be normal and uncomplicated. And in RA9172, the nurse is now allowed to suture perineal lacerations provided s/he has had the special training. Also, in this law, there is no longer an explicit provision stating that the nurse still needs special training for IV insertion. 132. Birth Control Methods and Infertility: In basal body temperature (BBT) technique, the sign that ovulation has occurred is an elevation of body temperature by A. 1.0-1.4 degrees centigrade B. 0.2-0.4 degrees centigrade C. 2.0-4.0 degrees centigrade D. 1.0-4.0 degrees centigrade Answer: (B) 0.2-0.4 degrees centigrade The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body temperature of about 0.2 – 0.4 degrees centigrade 133. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if A. The mother breast feeds mainly at night time when ovulation could possibly occur B. The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings C. The mother uses mixed feeding faithfully D. The mother breastfeeds regularly until 1 year with no supplemental feedings Answer: (B) The mother breastfeeds exclusively and regularly during the first 6

months without giving supplemental feedings A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhea. There is evidence to support the observation that the benefits of lactation amenorrhea lasts for 6 months provided the woman has not had her first menstruation since delivery of the baby. 134. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT A. Endometrium inflames B. Fundus contracts to expel uterine contents C. Copper embedded in the IUD can kill the sperms D. Sperms will be barred from entering the fallopian tubes Answer: (D) Sperms will be barred from entering the fallopian tubes An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the initial reaction is to produce inflammatory process and the uterus will contract in order to try to expel the foreign body. Usually IUDs are coated with copper to serve as spermicide killing the sperms deposited into the female reproductive tract. But the IUD does not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through. 135. Oral contraceptive pills are of different types. Which type is most appropriate for mothers who are breastfeeding? A. Estrogen only B. Progesterone only C. Mixed type- estrogen and progesterone D. 21-day pills mixed type Answer: (B) Progesterone only If mother is breastfeeding, the progesterone only type is the best because estrogen can affect lactation. 136. The natural family planning method called Standard Days (SDM), is the latest type and easy to use method. However, it is a method applicable only to women with regular menstrual cycles between ___ to ___ days. A. 21-26 days B. 26-32 days C. 28-30 days D. 24- 36 days Answer: (B) 26-32 days Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days. There is no need to monitor temperature or mucus secretion. This natural method of family planning is very simple since all that the woman pays attention to is her cycle. With the aid of CycleBeads, the woman can easily monitor her cycles. 137. Which of the following are signs of ovulation? 1. 2. 3. 4. A. Mittelschmerz; Spinnabarkeit; Thin watery cervical mucus; Elevated body temperature of 4.0 degrees centigrade 1&2

B. 1, 2, & 3 C. 3 & 4 D. 1, 2, 3, 4 Answer: (B) 1, 2, & 3 Mittelschmerz, spinnabarkeit and thin watery cervical mucus are signs of ovulation. When ovulation occurs, the hormone progesterone is released which can cause a slight elevation of temperature between 0.2-0.4 degrees centigrade and not 4 degrees centigrade. 138. The following methods of artificial birth control works as a barrier device EXCEPT: A. Condom B. Cervical cap C. Cervical Diaphragm D. Intrauterine device (IUD) Answer: (D) Intrauterine device (IUD) Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium. Some IUDs have copper added to it which is spermicidal. It is not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube. 139. Which of the following is a TRUE statement about normal ovulation? A. It occurs on the 14th day of every cycle B. It may occur between 14-16 days before next menstruation C. Every menstrual period is always preceded by ovulation D. The most fertile period of a woman is 2 days after ovulation Answer: (B) It may occur between 14-16 days before next menstruation Not all menstrual cycles are ovulatory. Normal ovulation in a woman occurs between the 14th to the 16th day before the NEXT menstruation. A common misconception is that ovulation occurs on the 14th day of the cycle. This is a misconception because ovulation is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next menstruation. 140. If a couple would like to enhance their fertility, the following means can be done: 1. Monitor the basal body temperature of the woman everyday to determine peak period of fertility; 2. Have adequate rest and nutrition; 3. Have sexual contact only during the dry period of the woman; 4. Undergo a complete medical check-up to rule out any debilitating disease A. 1 only B. 1 & 4 C. 1,2,4 D. 1,2,3,4 Answer: (C) 1,2,4 All of the above are essential for enhanced fertility except no. 3 because during the dry period the woman is in her infertile period thus even when sexual contact is done, there will be no ovulation, thus fertilization is not possible.

141. In sympto-thermal method, the parameters being monitored to determine if the woman is fertile or infertile are: A. Temperature, cervical mucus, cervical consistency B. Release of ovum, temperature and vagina C. Temperature and wetness D. Temperature, endometrial secretion, mucus Answer: (A) Temperature, cervical mucus, cervical consistency The 3 parameters measured/monitored which will indicate that the woman has ovulated are- temperature increase of about 0.2-0.4 degrees centigrade, softness of the cervix and cervical mucus that looks like the white of an egg which makes the woman feel “wet”. 142. The following are important considerations to teach the woman who is on low dose (mini-pill) oral contraceptive EXCEPT: A. The pill must be taken everyday at the same time B. If the woman fails to take a pill in one day, she must take 2 pills for added protection C. If the woman fails to take a pill in one day, she needs to take another temporary method until she has consumed the whole pack D. If she is breast feeding, she should discontinue using mini-pill and use the progestin-only type Answer: (B) If the woman fails to take a pill in one day, she must take 2 pills for added protection If the woman fails to take her usual pill for the day, taking a double dose does not give additional protection. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. When a new pack is started, she can already discontinue using the second temporary method she employed. 143. To determine if the cause of infertility is a blockage of the fallopian tubes, the test to be done is A. Huhner’s test B. Rubin’s test C. Postcoital test D. None of the above Answer: (B) Rubin’s test Rubin’s test is a test to determine patency of fallopian tubes. Huhner’s test is also known as post-coital test to determine compatibility of the cervical mucus with sperms of the sexual partner. 144. Infertility can be attributed to male causes such as the following EXCEPT: A. Cryptorchidism B. Orchitis C. Sperm count of about 20 million per milliliter D. Premature ejaculation Answer: (C) Sperm count of about 20 million per milliliter Sperm count must be within normal in order for a male to successfully sire a child. The normal sperm count is 20 million per milliliter of seminal fluid or 50

million per ejaculate. 145. Spinnabarkeit is an indicator of ovulation which is characterized as: A. Thin watery mucus which can be stretched into a long strand about 10 cm B. Thick mucus that is detached from the cervix during ovulation C. Thin mucus that is yellowish in color with fishy odor D. Thick mucus vaginal discharge influence by high level of estrogen Answer: (A) Thin watery mucus which can be stretched into a long strand about 10 cm At the midpoint of the cycle when the estrogen level is high, the cervical mucus becomes thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to fertilize an ovum. This is called spinnabarkeit. And the woman feels “wet”. When progesterone is secreted by the ovary, the mucus becomes thick and the woman will feel “dry”. 146. Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is A. Prostate gland B. Seminal vesicle C. Testes D. Vas deferens Answer: (D) Vas deferens Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation. 147. Breast self examination is best done by the woman on herself every month during A. The middle of her cycle to ensure that she is ovulating B. During the menstrual period C. Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen D. Just before the menstrual period to determine if ovulation has occurred Answer: (C) Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen The best time to do self breast examination is right after the menstrual period is over so that the hormonal level is low thus the breasts are not tender. 148. A woman is considered to be menopause if she has experienced cessation of her menses for a period of A. 6 months B. 12 months C. 18 months D. 24 months Answer: (B) 12 months If a woman has not had her menstrual period for 12 consecutive months, she is considered to be in her menopausal stage.

149. Which of the following is the correct practice of self breast examination in a menopausal woman? A. She should do it at the usual time that she experiences her menstrual period in the past to ensure that her hormones are not at its peak B. Any day of the month as long it is regularly observed on the same day every month C. Anytime she feels like doing it ideally every day D. Menopausal women do not need regular self breast exam as long as they do it at least once every 6 months Answer: (B) Any day of the month as long it is regularly observed on the same day every month Menopausal women still need to do self examination of the breast regularly. Any day of the month is alright provided that she practices it monthly on the same day that she has chosen. The hormones estrogen and progesterone are already diminished during menopause so there is no need to consider the time to do it in relation to the menstrual cycle. 150. In assisted reproductive technology (ART), there is a need to stimulate the ovaries to produce more than one mature ova. The drug commonly used for this purpose is: A. Bromocriptine B. Clomiphene C. Provera D. Esrogen Answer: (B) Clomiphene Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. The mature ova are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and after 48 hours the fertilized ovum is inserted into the uterus for implantation.

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