PART I TEST I - Foundation of Professional Nursing Practice 1.

The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client¶s pulse. The standard that would be used to determine if the nurse was negligent is: a. The physician¶s orders. b. The action of a clinical nurse specialist who is recognized expert in the field. c. The statement in the drug literature about administration of terbutaline. d. The actions of a reasonably prudent nurse with similar education and experience. 2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/ l. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? a. I.V b. I.M c. Oral d. S.C

3. Dr. Garcia writes the following order for the client who has been recently admitted ³Digoxin .125 mg P.O. once daily.´ To prevent a dosage error, how should the nurse document this order onto the medication administration record? a. ³Digoxin .1250 mg P.O. once daily´ b. ³Digoxin 0.1250 mg P.O. once daily´ c. ³Digoxin 0.125 mg P.O. once daily´ d. ³Digoxin .125 mg P.O. once daily´

4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority? a. Ineffective peripheral tissue perfusion related to venous congestion. b. Risk for injury related to edema. c. Excess fluid volume related to peripheral vascular disease. d. Impaired gas exchange related to increased blood flow. 5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? a. A 34 year-old post operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operative¶s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities. c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift.

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. ³My ankle looks less swollen now´. b. ³My ankle feels warm´. c. ³My ankle appears redder now´. d. ³I need something stronger for pain relief´

10. The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 12. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. Protect the irritated skin from sunlight. b. Eat 3 to 4 hours before treatment. c. Wash the skin over regularly. d. Apply lotion or oil to the radiated area when it is red or sore. 17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. Encourage the client to void following preoperative medication. b. Explore the client¶s fears and anxieties about the surgery. c. Assist the client in removing dentures and nail polish. d. Encourage the client to drink water prior to surgery. 18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis? a. Blood pressure above normal range. b. Presence of crackles in both lung fields. c. Hyperactive bowel sounds d. Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. Provide high-fiber, high-fat diet b. Provide high-protein, high-carbohydrate diet. c. Monitor intake to prevent weight gain. d. Provide ice chips or water intake.

20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? a. Blood pressure and pulse rate. b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels.

21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action? a. Takes a set of vital signs. b. Call the radiology department for X-ray. c. Reassure the client that everything will be alright. d. Immobilize the leg before moving the client. 22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client? a. Place client on reverse isolation. b. Admit the client into a private room. c. Encourage the client to take frequent rest periods. d. Encourage family and friends to visit. 23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge

Planning and goals . 2. c. 66 cc/ hour 28. b. What is the priority action by the nurse? a. Evaluation c. Assess the dressing for drainage. place the client in a comfortable position. d. Assess the IV for type of fluid and rate of flow. The nurse in-charge is going to hang a 500 cc bag. 50 cc/ hour b. 29. Place the client in high-Fowlers position. b. Place the client on the left side in the Trendelenburg position. 24 cc/ hour d. BP ± 130/80. Assess the client for presence of pain. Autocratic.5 cc 27. if you are not sure of the size of cuff to use. BP ± 180/100. b. which extremity was used. 25.Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. Situational 26. Stop the total parenteral nutrition. BP ± 80/60. The IV drip factor is 60. Pulse ± 100 regular d. c.Nurse May attends an educational conference on leadership styles.5 cc d.Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process? a. 55 cc/ hour c. Pulse ± 90 irregular 30. Document the measurement. Democratic. and the position that the client was in during the measurement. How many cc¶s of KCl will be added to the IV solution? a. d. c. Take the proper equipment. The nurse determines that the leadership style used at the trauma center is: a.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. 5 cc c. . Notify the physician. and record the appropriate information in the client¶s chart. Assessmen t b.24.5 cc b. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. d. KCl is supplied 20 mEq/10 cc. Pulse ± 110 irregular b. b. Laissez-faire. Measure the client¶s arm. BP ± 90/50. Assess the Foley catheter for patency and urine output d. c. 1. Implementation d. 31. Pulse ± 50 regular c. The IV rate that will deliver this amount is: a.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a.The nurse is aware that the most important nursing action when a client returns from surgery is: a.

32. It¶s the basis for solids in the avoirdupois system. Physical examination 33. Diagnostic test results b. Stage III d. Footboard d. Pillows under the lower legs. It¶s a common measurement in the metric system. b. It¶s the smallest measurement in the apothecary system.M. 0. Stage IV 35. 0. 48 °C d.25 38. c.´ How many milliliters of meperidine should the client receive? a. d. 0. Distended neck veins d. Primary intention healing c.The physician prescribes meperidine (Demerol). 75 mg I. Stage II c.5 d. 38 °C .In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time. History of present illness d.75 b. It¶s a measure of effect. to control a client¶s postoperative pain. Hip-abductor pillow 34. First intention healing 36. Which statement correctly describes an insulin unit? a. Trochanter roll extending from the crest of the ileum to the midthigh. Biographical date c.Nurse Oliver measures a client¶s temperature at 102° F. Stage I b. c.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. not a standard measure of weight or quantity.Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person¶s needs? a.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Third intention healing d.When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations. Nurse Oliver learns that the client lives alone and hasn¶t been eating or drinking. The package insert is ³Meperidine. 40. What is the equivalent Centigrade temperature? a. 38. b. Hypothermia b.1 °C b. every 4 hours as needed. the wound healing is termed a. Second intention healing b. the most appropriate nursing action would be to use: a. Hypertension c. nurse Oliver would expect to find: a. 39. Tachycardia 37. 100 mg/ml. When assessing him for dehydration. A male client with diabetes mellitus is receiving insulin.6 c.9 °C c. 0.

Retrospective 48. State the client¶s name out loud and wait a client to repeat it. to establish baseline . Increasing loss of muscle tone. Keeping the head of the bed slightly elevated. has no family history of breast cancer or other risk factors for this disease. The nurse in-charge can prevent chest tube air leaks by: a. Fingertips b.000 ml to be infused over 8 hours. One of the first physical signs of aging is: a.The physician inserts a chest tube into a female client to treat a pneumothorax. Finger pads c. 30 drops/minute b. Keeping the chest drainage system below the level of the chest. The I. Auscultation. c. Nurse John should run the I. and percussion. She has fever. Apply a dry sterile dressing to the site. Nurse Hazel inspects the client¶s abdomen and notice that it is slightly concave. Ulnar surface of the hand 47. Clamp the catheter b. b. Check the client¶s identification band. b.If a central venous catheter becomes disconnected accidentally. Dorsal surface of the hand d.A 45 year old client. c. 1. Nurse John should instruct her to have mammogram how often? a. what should the nurse in-charge do immediately? a. d. Once per year c. palpation. Nurse Betty is assessing tactile fremitus in a client with pneumonia. c. Palpation. 32 drops/minute c.40. d. Check the room number and the client¶s name on the bed.V. Call the physician d. c. Once. Ask the client to state his name. 20 drops/minute d.The physician orders dextrose 5 % in water. The tube is connected to waterseal drainage. auscultation. especially close vision. Failing eyesight.V. tubing delivers 15 drops/ml.A female client was recently admitted. and palpation. 18 drops/minute 44. 41. Palpation. Which type of evaluation occurs continuously throughout the teaching and learning process? a. 45. Having more frequent aches and pains.The nurse is assessing a 48-year-old client who has come to the physician¶s office for his annual physical exam. Accepting limitations while developing assets. Every 2 years d. 46. Percussion. d. Additional assessment should proceed in which order: a. and auscultation. She is aware that the safest way to verify identity is to: a. percussion. For this examination. 43. and auscultation. Call another nurse c. nurse Betty should use the: a. b. Checking and taping all connections. and watery diarrhea is being admitted to the facility. While assessing the client. Checking patency of the chest tube.Nurse Trish must verify the client¶s identity before administering medication. b. weight loss. Informative c. Summative b. Twice per year b. 42. percussion. d. Formative d. infusion at a rate of: a.

Metabolic acidosis d. Knee b. 55. which of the following actions can the nurse institute independently? a. Applying an antibiotic cream to the area three times per day. To provide support for the client and family in coping with terminal illness. Foot 53. The nurse rushes to the client¶s room. c. 52. Metabolic alkalosis 50. Based on these values. Hypokalemia c.49. On the unaffected side of the client.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Tinnitus or diplopia. Prepare to defibrillate the client c.30. Lower thigh d. Nervousness or paresthesia. Hypernatremia b. d.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client.Nurse Michelle hears the alarm sound on the telemetry monitor. What is the goal of this referral? a. 51. . d. the nurse would take which action first? a. Hypercalcemia 54.Nurse Oliver must apply an elastic bandage to a client¶s ankle and calf.Nurse Hazel is preparing to ambulate a female client. c. d.A male client has the following arterial blood gas values: pH 7. To ensure that the client gets counseling regarding health care costs. Paco2 50 mmHg. c. Throbbing headache or dizziness b. Which condition represents the greatest risk to this child? a. Immediately afterward. d. Pao2 89 mmHg. b. Respiratory acidosis b. Respiratory alkalosis c. Check the client¶s level of consciousness 56. Upon reaching the client¶s bedside. the client may experience: a. Call a code d. b. To help the client find appropriate treatment options. To teach the client and family about cancer and its treatment. Using a povidone-iodine wash on the ulceration three times per day. and HCO3 26mEq/L. The best and the safest position for the nurse in assisting the client is to stand: a. Ankle c. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. b. He should apply the bandage beginning at the client¶s: a. On the affected side of the client.Nurse Len refers a female client with terminal cancer to a local hospice. Hyperphosphatemia d. Behind the client. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. c.When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx. In front of the client. Prepare for cardioversion b. Nurse Patricia should expect which condition? a. Drowsiness or blurred vision. Massaging the area with an astringent every 2 hours.

moves the walker forward. Clamping the tubing of the drainage bag. and then walks into it. Erases the error and writes in the correct information.Nurse Meredith is in the process of giving a client a bed bath. Draws one line to cross out the incorrect information and then initials the change. puts weight on the hand pieces. c. Provide tissues for expectoration and obtaining the specimen. Instructs the client to move self from the table to the stretcher. Ask the client to expectorate a small amount of sputum into the emesis basin. b. the nurse realizes that incorrect information was documented. which contaminate the specimen? a. Covers up the incorrect information completely using a black pen and writes in the correct information 63. 62. c. In the middle of the procedure. Puts weight on the hand pieces. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. Obtaining the specimen from the urinary drainage bag.Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. Wiping the port with an alcohol swab before inserting the syringe. the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. 60. c. and answer the phone call. . c. b. Moves the client rapidly from the table to the stretcher. Puts all the four points of the walker flat on the floor. Uses correction fluid to cover up the incorrect information and writes in the correct information. Uncovers the client completely before transferring to the stretcher. place the call light within reach. The appropriate nursing action is to: a. b. and then walks into it. c. b. b. Nurse Janah plans to implement which intervention to obtain the specimen? a. c. d. Finish the bed bath before answering the phone call. d. d. Urine output: 45 ml/hr b. Leave the client¶s door open so the client can be monitored and the nurse can answer the phone call. d. The nurse determines that the client is using the walker correctly if the client: a. 59.57. b. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. d. puts weight on the hand pieces. When checking the entry. and then puts all four points of the walker flat on the floor. d. How does the nurse correct this error? a. Serum pH: 7. and then walks into it. Ask the client to obtain the specimen after breakfast. Aspirating a sample from the port on the drainage bag. Walks into the walker.Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. the nurse should: a. Use a sterile plastic container for obtaining the specimen. Immediately walk out of the client¶s room and answer the phone call. slides the walker forward. Blood pressure: 90/48 mmHg 58. Capillary refill: 5 seconds c.32 d.Nurse Amy has documented an entry regarding client care in the client¶s medical record. The nurse determines that the standard of care had been maintained if which of the following data is observed? a. Nurse Ron is observing a male client using a walker. The nurse avoids which of the following. Puts weight on the hand pieces. Secures the client safety belts after transferring to the stretcher. To provide safety to the client. Cover the client. 61.

c. Left side-lying with the head of the bed elevated 45 degrees.Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Keep the identities of the subject secret b. Field study b.Nurse John develops methods for data gathering. Sims¶ position with the head of the bed flat. Crutches b. Experiment c. Provide equal treatment to all the subjects of the study. What type of research is appropriate for this study? a.64. Reliability 68. Historical 70. Which type of research is referred to this? a. Gown and gloves c. Right side-lying with the head of the bed elevated 45 degrees. 67. Observation 71. Single straight-legged cane c. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath? a. Use of laboratory data d. Gown and goggles b.Harry knows that he has to protect the rights of human research subjects. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? a. the nurse assists the client to which position for the procedure? a.Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Gloves and goggles 65. Quasi-experiment c.correlational b. Prone with head turned toward the side supported by a pillow. Validity b. Sensitivity d. d. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. Descriptive. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? a. Questionnaire c. Obtain informed consent c. Specificity c.Nurse Ronald is aware that the best tool for data gathering is? a. Solomon-Four group design d. Gloves and shoe protectors d. Release findings only to the participants of the study 69. The client experiences severe dizziness when sitting upright. Quad cane d. Post-test only design . The client has right sided arm and leg weakness. Which of the following actions of Harry ensures anonymity? a. To provide a safe environment. Quasi-experiment d. Interview schedule b.A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. Walker 66. d. b.Patient¶s refusal to divulge information is a limitation because it is beyond the control of Tifanny´.

Solidarity 74. Respondeat superior c. Which of the following actions of is correct? a. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. Design the theoretical and conceptual framework 78. Justice d. place these in a fishbowl and draw 10 from it. An example of this power is: a. Madeleine Leininger c.Ronald plans to conduct a research on the use of a new method of pain assessment scale. Horns effect 79. Review related literature c. the presence of the injury is said to exemplify the principle of: a. The Board can investigate violations of the nursing law and code of ethics c. Halo effect d.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. When the license of nurse Krina is revoked. Determines the different nationality of patients frequently admitted and decides to get representations samples from each. d. Primary source d. Endnotes 73. The Board can issue rules and regulations that will govern the practice of nursing b.72. Florence Nightingale b. Will remain unable to practice professional nursing 77. b.When Nurse Trish is providing care to his patient.When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act. Albert Moore d. Is no longer allowed to practice the profession for the rest of her life b. Hawthorne effect c. The Board prepares the board examinations 76.Mary finally decides to use judgment sampling on her research. Res ipsa loquitor d. This referred to as : a. Decides to get 20 samples from the admitted patients 80. Assigns numbers for each of the patients. Plans to include whoever is there during his study. Non-maleficence b. Formulating and delimiting the research problem d. Sr. The Board can visit a school applying for a permit in collaboration with CHED d. Force majeure b. Will never have her/his license re-issued since it has been revoked c. Which type of reference source refers to this? a. Footnote b. Bibliography c. Beneficence c. This is the meaning of the bioethical principle: a. Holdover doctrine 75. she must remember that her duty is bound not to do doing any action that will cause the patient harm. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 d.Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. it means that she: a. Cause and effect b. The nursing theorist who developed transcultural nursing theory is: a. c. Which of the following is the second step in the conceptualizing phase of the research process? a. Callista Roy . Formulating the research hypothesis b.

Nurse Marian is preparing to administer a blood transfusion. Measure the client¶s vital signs. Degree of acceptance c. b.m. Nurse Reese should include which instruction? a. Callista Roy c. Dependent 91. Florence Nightingale d. b.Nurse Reese is teaching a female client with peripheral vascular disease about foot care. without redness or edema. instead of 10 p.Which of the following theory addresses the four modes of adaptation? a. Fresh orange slices b. Ground beef patties 88. Autonomy c. Prone d. Evaluation . Judgment 83. Avoid wearing cotton socks. 87. Independent d. Unity of command c. When developing the client's diet plan. Non-maleficence 86. Sims¶ left lateral 89.81. the nurse should include: a. Leader 85. Beneficence b. Veracity d. Which action should the nurse take first? a. Sr. Span of control b. Lithotomy b. Interdependent a. Assessment b. Quota d. Which type of nursing intervention is required? c. c. Downward communication d. Diagnosis c. Avoid using cornstarch on feet. Degree of agreement and disagreement b. Random b. infusion of normal saline solution. 90. This principle refers to: a. What is the most common client position used for this procedure? a.V.The nurse prepares to administer a cleansing enema. c.John plans to use a Likert Scale to his study to determine the: a. Accidental 82. Start an I. d. The nurse's actions reflect which step of the nursing process? a. Steamed broccoli c. Intradependent b. Garcia is responsible to the number of personnel reporting to her. so that he can go to sleep earlier. Compliance to expected standards c. d. Supine c.m. Compare the client¶s identification wristband with the tag on the unit of blood.A 65 years old male client requests his medication at 9 p.A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis.A client is admitted with multiple pressure ulcers. illustrates the bioethical principle of: a. Ice cream d. Jean Watson 84. Implementation d.Ms. Avoid wearing canvas shoes.Ensuring that there is an informed consent on the part of the patient before a surgery is done. Arrange for typing and cross matching of the client¶s blood. The Nurse Betty notes that the client's leg is pain-free. Madeleine Leininger b. Avoid using a nail clipper to cut toenails.Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is: a. Level of satisfaction d.

94. c. 4 hours c.Nurse May is aware that the main advantage of using a floor stock system is: a. c. The system minimizes transcription errors. 2 hours 98. The nurse receives input from the pharmacist. Shifting dullness over the abdomen. b. Change the feeding container every 12 hours. b. c. d. To allow the leg muscles to stretch and relax d. or dyspnea. To increase blood flow to the heart b.Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? a.Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. Documenting blood administration in the client care record. Give the feedings at room temperature. 97. b. Dullness over the liver. d.Nursing care for a female client includes removing elastic stockings once per day. c. Do nothing. Shake the vial vigorously. b. b. d. 30 minutes after administering the next dose. Vascular sounds heard over the renal arteries. 3 hours d. Invert the vial and let it stand for 3 to 5 minutes. Assist the client to the semi-Fowler position if possible. 1 hour before administering the next dose. .The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. The nurse can implement medication orders quickly. Assessing the client¶s vital signs when the transfusion ends. b. 6 hours b.Nurse Monique is monitoring the effectiveness of a client's drug therapy. 99. to 2 hours. she nurse should: a. Secure the elastic band tightly around the client's head. After adding the solution to the powder. Immediately after administering the next dose. d. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. The system reinforces accurate calculations. c. c. 100. Which intervention is most appropriate for this problem? a. Instructing the client to report any itching.Nurse Patricia is reconstituting a powdered medication in a vial.A male client complains of abdominal discomfort and nausea while receiving tube feedings. Decrease the rate of feedings and the concentration of the formula. 95. To permit veins in the legs to fill with blood. Informing the client that the transfusion usually take 1 . b. d. Place the client in semi-Fowler's position while feeding. The Nurse Betty is aware that the rationale for this intervention? a. To observe the lower extremities c. Nurse Oliver is assessing a client's abdomen. 96. Roll the vial gently between the palms. Immediately before administering the next dose. Loosen the connectors between the oxygen equipment and humidifier. Apply the face mask from the client's chin up over the nose.92. c. d. Bowel sounds occurring every 10 seconds. 93. d. Which finding should the nurse report as abnormal? a. swelling.

Increased caloric intake c. 8. Which of the following data. Inevitable b. Age 36 years b. b. Decreased Insulin d. Septic 2. A pregnant client is receiving oxytocin (Pitocin) for induction of labor.Community Health Nursing and Care of the Mother and Child 1. 7. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). b. The nurse determines that May is experiencing which type of abortion? a. Contractions every 1 . the nurse notes that May has a dilated cervix. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. A condition that warrant the nurse incharge to discontinue I. Urinary output 90 cc in 2 hours.V. b. Monitoring temperature 4. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Presenting part in 2 cm below the plane of the ischial spines. b. would alert the nurse that the client is at risk for a spontaneous abortion? a. correctly interprets it as: a. Early decelerations in the fetal heart rate. c. minutes lasting 70-80 seconds.TEST II . 6. Monitoring apical pulse d. Biparietal diameter is 2 cm above the ischial spines. She is aware that one of the following is unassociated with this condition? a. Elevated levels of human chorionic gonadotropin. History of syphilis c. Monitoring weight b. . During vaginal examination of Janah who is in labor. c. Incomplete c. Rapid respiratory rate above 40/min. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole.2 c. Excessive fetal activity. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. Nurse. History of genital herpes d. c. Vaginal bleeding d. Threatened d. d. Increase Insulin 5. Fetal heart rate baseline 140-160 bpm. The clinical findings that would warrant use of the antidote . calcium gluconate is: a. infusion of Pitocin is: a. History of diabetes mellitus 3. Rapid rise in blood pressure. During the physical examination of the client. Decreased caloric intake b. the presenting part is at station plus two. Biparietal diameter is at the level of the ischial spines. if noted on the client¶s record. d. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? a. Assessing for edema c. Absent patellar reflexes. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. d. Larger than normal uterus for gestational age. Presenting part is 2 cm above the plane of the ischial spines. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require: a. Maternal temperature 101.

Fetus in this pregnancy is in a vertex presentation. Services are provided free of charge to people within the catchments area.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site? a. First low transverse cesarean was for active herpes type 2 infections. The public health nurse functions as part of a team providing a public health nursing services. Public health nursing focuses on preventive. A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. c.Which of the following is the most prominent feature of public health nursing? a. 15. Iron-rich formula and baby food. Bring extra help so it can be done quickly. First and second caesareans were for cephalopelvic disproportion. 6 months b. c. Place the infant¶s arms in soft elbow restraints. even when cleaning. services. . 4 months c. b. 11. Bathe the infant and administer medications before feeding.Mommy Linda is playing with her infant. The nurse should advise her to include which foods in her infant¶s diet? a.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler¶s temperature is: a. c. b. Iron-rich formula only. First caesarean through a classic incision as a result of severe fetal distress. EKG tracings d. Ignore the crying and screaming. c. vaginal culture at 39 weeks pregnancy was positive. b. would likely to be given to a gravida. It involves providing home care to sick people who are not confined in the hospital. Weigh and bathe the infant before feeding. Whole milk and baby food. b. Talk to the mother first and then to the toddler. d. Place the baby in prone position. Ventilator assistance b. 10 months 16. Give the baby a pacifier. d. d. 12.9. A trial for vaginal delivery after an earlier caesareans. CVP readings c. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. 8 months d. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). Allow the infant to rest before feeding. Continuous CPR 10. who had: a. 13. d. Avoid touching the suture line. c. Feed the infant when he cries. The mother hides a toy behind her back and the infant looks for it. First low transverse caesarean was for breech position. d.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. b. 14. Skim milk and baby food. Encourage the mother to hold the child. b. not curative. who is sitting securely alone on the floor of the clinic. c. The nurse is aware that estimated age of the infant would be: a. d.

Myra is the public health nurse in a municipality with a total population of about 20. Which of the following best illustrates this statement? a. Community organization c. d. 4 as a target for eradication in the Philippines is? a. Rabies d. Integration b. Community health nursing is intended primarily for health promotion and prevention and treatment of disease.Tertiary prevention is needed in which stage of the natural history of disease? a. Any qualified physician 20.S. Department of Health b. Municipal Health Officer c. Terminal . 21.Vangie is a new B.According to Freeman and Heinrich. Pathogenesis d. Effectiveness b. b. There are 3 rural health midwives among the RHU personnel.Beth a public health nurse takes an active role in community participation. she is evaluating a. Provincial Health Office c.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas. Regional Health Office d. graduate. 2 c. Efficiency c. The RHU does not need any more midwife item. Where should she apply? a. Core group formation 24. Adequacy d. Community study d. d.17. Rural Health Unit 19. 25.May knows that the step in community organizing that involves training of potential leaders in the community is: a. Poliomyelitis b. Prodromal b.N. community health nursing is a developmental service. Measles c. Neonatal tetanus 23. She wants to become a Public Health Nurse. The community health nurse continuously develops himself personally and professionally. c. To mobilize the people to resolve community health problems c. Health education and community organizing are necessary in providing community health services.000. Mayor b. The goal of community health nursing is to provide nursing services to people in their own places of residence. Public Health Nurse d.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 1 b. To maximize the community¶s resources in dealing with health problems. 22. 3 d. What is the primary goal of community organizing? a. Pre-pathogenesis c. How many more midwife items will the RHU need? a. To maximize the community¶s resources in dealing with health problems.Tony is aware the Chairman of the Municipal Health Board is: a. Appropriateness 18. To educate the people regarding community health problems b.

Intrauterine fetal death. Atrial septal defect b. Change the diaper more often. Menorrhagia b. Wash the area vigorously with each diaper change. Endocardial cushion defect 30. c. Placenta accreta. Apply talc powder with diaper changes. Decrease the infant¶s fluid intake to decrease saturating diapers. d. d.V. Blood typing d. Iron binding capacity c. A 2 year old infant with stridorous breath sounds. Nurse Betty is aware that the fetal heart rate would be: a. Increased respiratory rate 31. Physiologic anemia 34. b. c. Pulmonic stenosis c.Nurse Lynette is working in the triage area of an emergency department. Hyperreflexia d. Who needs to be treated first is: a. 27. Mastitis d. Premature rupture of the membranes. Metabolic alkalosis b. The critical laboratory result for this client would be: a.Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is: a. Anemia b. Oxygen saturation b. Serum Calcium 33. Dyspareunia d.The skin in the diaper area of a 7 month old infant is excoriated and red. Ventricular septal defect d. b. Amenorrhea 32. c.Malou was diagnosed with severe preeclampsia is now receiving I.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? a. 29. 100 to 120 beats/minute c. A 3 year old child with Down syndrome who is pale and asleep in his mother¶s arms. Dysfunctional labor. Nurse Hazel should instruct the mother to: a. d. This type of menstrual pattern is bets defined by: a.26. magnesium sulfate. Respiratory acidosis c. The adverse effects associated with magnesium sulfate is: a. A crying 5 year old child with a laceration on his scalp. Decreased urine output c.The nurse is caring for a primigravid client in the labor and delivery area. 160 to 180 beats/minute 28. 120 to 160 beats/minute d. . A 4 year old child with a barking coughs and flushed appearance. 80 to 100 beats/minute b.A fullterm client is in labor. b.Jannah is admitted to the labor and delivery unit. Metrorrhagia c. sitting up in his mother¶s arms and drooling.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is: a.

The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool. Restlessness d. Nurse Olivia should expect that the child most likely would have an: a. Without touching the child.To evaluate a woman¶s understanding about the use of diaphragm for family planning. Walk one step ahead.In doing a child¶s admission assessment.When assessing a newborn diagnosed with ductus arteriosus. gently guiding the child forward. ³I may need a different size of diaphragm if I gain or lose weight more than 20 pounds´ c. c. machinery-like murmur. The community nurse collects a stool specimen to confirm the diagnosis. d. Sexually transmitted disease 36. and the newborn¶s metabolic rate decreases. Loud. The nurse should schedule the collection of this specimen for: a. c. ³I should check the diaphragm carefully for holes every time I use it´ b. Less oxygen. and the newborn¶s metabolic rate increases. holding the child¶s hand. 42.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Dehydration and diarrhea c. the neonate requires: a. talk continuously as the child walks down the hall. Increased BP reading in the upper extremities. b. More oxygen. Less oxygen. 39. Bradycardia and hypotension d. Which of the following conditions is suspected? a. .A young child named Richard is suspected of having pinworms. d. c. Abruptio placentae c. Any time during the day d. Irritability and seizures b. Low-grade fever 40. and the newborn¶s metabolic rate decreases. Just before bedtime b. Walk slightly behind. Premature labor d. Placenta previa b. Muffled voice c. Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning? a. More oxygen. Which response indicates a need for further health teaching? a.How should Nurse Michelle guide a child who is blind to walk to the playroom? a. Decreased BP reading in the upper extremities d. Nurse Trish asks her to explain how she will use the appliance. Bluish color to the lips. with the child¶s hand on the nurse¶s elbow. b. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for: a. After the child has been bathe c. ³The diaphragm must be left in place for atleast 6 hours after intercourse´ d. Walk next to the child.Hypoxia is a common complication of laryngotracheobronchitis. Drooling b. and the newborn¶s metabolic rate increases. b. ³I really need to use the diaphragm and jelly most during the middle of my menstrual cycle´.35. Early in the morning 37. 41. Petechiae and hematuria 38.

The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism? a.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of ³rice water´ stools. Baby oil b.V.Barangay Pinoy had an outbreak of German measles. b. A single attack of chicken pox will prevent future episodes. Consult a physician who may give them rubella immunoglobulin. Powder with cornstarch 45. Patant fontanelles c.Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections. including conditions such as shingles. quarantine may be imposed by health authorities. Chicken pox vaccine is best given when there is an impending outbreak in the community. Community survey c. Stable blood pressure b. The older one gets. 48. Nurse Ron must be sure to assess whether this infant has: a. Hepatitis A b. Contact tracing b. To prevent congenital rubella. 47. Advice them on the signs of German measles. A week after the start of fever. d. 6 inches b. To prevent an outbreak in the community. line. Morbillivirus c. Nurse Lhynnete discussed childhood diseases such as chicken pox. Voided 44.During tube feeding. Avoid crowded places. Neisseria meningitidis . Steptococcus pneumoniae d. b. Moro¶s reflex d. Hepatitis B c. Which of the following statements about chicken pox is correct? a. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. In a mothers¶ class. Based on her history. 18 inches d.A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Tetanus d. Mass screening tests d. Amebiasis d. The client is most probably suffering from which condition? a. the more susceptible he becomes to the complications of chicken pox.Before adding potassium to an infant¶s I. what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy? a. Accompanying symptoms were muscle pains and body malaise. how far above an infant¶s stomach should the nurse hold the syringe with formula? a.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is: a. Laundry detergent d. Leptospirosis 50. Hemophilus influenzae b. Consult at the health center where rubella vaccine may be given. the client noted yellowish discoloration of his sclera. 24 inches 46. Cholera c. Interview of suspects 49. such as markets and movie houses.43. c. Dysentery 51. 12 inches c. Giardiasis b. Baby lotion c. the BEST method that may be undertaken is: a. which disease condition will you suspect? a. d. c.

65 infants 56. DPT b. Use of protective footwear. Which of the following clients should be classified as a case of multibacillary leprosy? a. Macular lesions b. Thickened painful nerves d.Marie brought her 10 month old infant for consultation because of fever. .The student nurse is aware that the pathognomonic sign of measles is Koplik¶s spot and you may see Koplik¶s spot by inspecting the: a. Severe pneumonia d. positive slit skin smear c. Building of foot bridges c. Severe febrile disease 55. Nasal mucosa b.52. 10 seconds 54. the nurse is aware that the severe conditions generally require urgent referral to a hospital.Several clients is newly admitted and diagnosed with leprosy. MMR 57. positive slit skin smear 59. Perform a tourniquet test. 3 seconds b.In Integrated Management of Childhood Illness. Buccal mucosa c. 9 seconds d. b.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds? a. Sinking of the nosebridge 60. Mastoiditis b.The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? a. what will you do? a. Get a specimen for blood smear.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. negative slit skin smear b. 50 infants c. The estimated number of infants in the barangay would be: a. 3 skin lesions. Skin on neck 53. 6 seconds c. c. 5 skin lesions. Oral polio vaccine c. Which of the following is an early sign of leprosy? a. Ask where the family resides. 5 skin lesions. such as rubber boots 58. Severe dehydration c. started 4 days prior to consultation.Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Proper use of sanitary toilets d. 3 skin lesions. Ask if the fever is present everyday. negative slit skin smear d. Measles vaccine d. d.It is the most effective way of controlling schistosomiasis in an endemic area? a. 55 infants d. Inability to close eyelids c. Skin on the abdomen d. Use of molluscicides b. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? a. In determining malaria risk. 45 infants b.

Following the IMCI assessment guide. using the IMCI guidelines. Assess and treat the child for health problems like infections and intestinal parasitism.Gina is using Oresol in the management of diarrhea of her 3-year old child. 3 years c. Inability to drink b. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment. Bring the child to the health center for intravenous fluid therapy. 1 year d. c. She is aware that her baby will have protection against tetanus for a. Using the IMCI guidelines.Jimmy a 2-year old child revealed ³baggy pants´. his breathing is considered as: a. At the end of the day 68. She asked you what to do if her child vomits. 1 year b. As a nurse you will tell her to: a. 5 years d. Refer the child urgently to a hospital for confinement. No signs of dehydration b. Coordinate with the social worker to enroll the child in a feeding program.Maylene had just received her 4th dose of tetanus toxoid. 4 hours c. Let the child rest for 10 minutes then continue giving Oresol more slowly. Lifetime 67. Her skin goes back slowly after a skin pinch and her eyes are sunken. you will classify this infant in which category? a. 64. which of the following is a danger sign that indicates the need for urgent referral to a hospital? a. Slow c. Make a teaching plan for the mother. Signs of severe dehydration d. Bring the child to the health center for assessment by the physician. d. 2 hours b. c. b. As a nurse. d. how will you manage Jimmy? a. Severe dehydration d. 8 hours d. 2 years .Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. 6 months c. Insignificant 66. His respiratory rate is 42/minute. b. The data is insufficient. Cough for more than 30 days 62.Susie brought her 4 years old daughter to the RHU because of cough and colds.Chris a 4-month old infant was brought by her mother to the health center because of cough.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby¶s nutrient needs only up to: a. High grade fever c. Normal d. focusing on menu planning for her child.61. 5 months b.Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution? a. Bring the child to the nearest hospital for further assessment. Some dehydration c. Fast b. 63. 65.

Lanugo covering the body c. Anemia probably due to chronic fetal hyposia b. Vernix caseosa covering the body 74.After reviewing the Myrna¶s maternal history of magnesium sulfate during labor. Apply peroxide to the cord with each diaper change b. Cover the cord with petroleum jelly after bathing c. When teaching umbilical cord care for Jennifer a new mother. the nurse Jenny would include which information? a. Gastroesophageal reflux (GER) 71. Light audible grunting c. Which of the following findings is considered common in the healthy neonate? a. Jitteriness c. Wash the cord with soap and water each day during a tub bath. Respiratory rate 40 to 60 breaths/minute d. Sudden infant death syndrome (SIDS) c.Nurse John is performing an assessment on a neonate. Conjunctival hemorrhage c. Flushed cheeks b. Simian crease b. A sleepy. Polycythemia probably due to chronic fetal hypoxia 73.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without difficulty? a. which physical finding is expected? a. Desquamation of the epidermis d. Bulging fontanelle . Increased temperature c. 77. Suffocation d. 12 weeks c. Respiratory rate 60 to 80 breaths/minute 76. 8 weeks b.69. which condition would nurse Richard anticipate as a potential problem in the neonate? a. the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following? a. Decreased temperature d. Hyperthermia due to decreased glycogen stores c.Which finding might be seen in baby James a neonate suspected of having an infection? a. Increased activity level 72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication? a. Respiratory depression d.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is: a.Marjorie has just given birth at 42 weeks¶ gestation. Nasal flaring b. 24 weeks d. Hypoglycemia b. When the nurse assessing the neonate. Tachycardia 75. Aspiration b. Cystic hygroma d.When teaching parents of a neonate the proper position for the neonate¶s sleep. lethargic baby b. 32 weeks 70. Keep the cord dry and open to air d. Hyperglycemia due to decreased glycogen stores d.

³Do you have any chronic illnesses?´ b. the nurse Hazel checks the fetal heart tones for which the following reasons? a. and placed on a ventilator. Notify the physician. A pregnant woman accompanied by her husband. When a client states that her "water broke. Keep her body temperature low. b. Which of the following is normal newborn calorie intake? a. d. Provide oxygen via face mask as ordered d. Observing for flakes of vernix in the vaginal discharge. The parents¶ indication that they want to see the newborn. Conducting a bedside ultrasound for an amniotic fluid index. c. 85. To prepare for an imminent delivery. cyanosis. Within several hours she develops respiratory grunting. At least 2 ml per feeding d. 81. tachypnea. ³What is your expected due date?´ d. Cover his eyes while receiving oxygen. b. b. Instructing the client about the importance of perineal (kegel) exercises. The parents¶ interactions with each other. and retractions. b. nasal flaring. c. 90 to 100 calories per kg c. 110 to 130 calories per kg. seeks admission to the labor and delivery area. Following this procedure. Instructing the client on the use of sitz baths if ordered. Observing the pooling of straw-colored fluid." which of the following actions would be inappropriate for the nurse to do? a. Aspirate the neonate¶s nose and mouth with a bulb syringe. At birth. she has no spontaneous respirations but is successfully resuscitated. 84. What should the nurse do first? a. d. ³Do you have any allergies?´ c. 83. examination of the client's vagina reveals a fourth-degree laceration. To determine fetal well-being. Checking vaginal discharge with nitrazine paper.A neonate begins to gag and turns a dusky color. b. She's diagnosed with respiratory distress syndrome. c. Esteves decides to artificially rupture the membranes of a mother who is on labor. 30 to 40 calories per lb of body weight. 79. c. intubated. The parent¶s expression of interest about the size of the new born. d.78. To assess fetal position d. ³Who will be with you during labor?´ 82. Instructing the client to use two or more peripads to cushion the area. b. Which of the following would be contraindicated when caring for this client? a. Calm the neonate. Humidify the oxygen.Following a precipitous delivery. Monitor partial pressure of oxygen (Pao2) levels. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? a. Applying cold to limit edema during the first 12 to 24 hours. . c.Dr. b. The parents¶ willingness to touch and hold the new born. A baby girl is born 8 weeks premature.Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? a. Which question should the nurse Oliver ask her first? a. 80. She states that she's in labor and says she attended the facility clinic for prenatal care. d. To assess for prolapsed cord c.

A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours. Antihypertensive agents b. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. fluids d. Oral hypoglycemic drug and insulin 91. Digital or speculum examination c. c. Increased tidal volume b.V. Naloxone (Narcan) d. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks? a. 30 to 32 weeks d.86. Increased expiratory volume c. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. External fetal monitoring d. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. d. Rho (D) immune globulin (RhoGAM) 94. 16 to 18 weeks b. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours. I. conjoined twins b. 38 to 40 weeks 87. Which of the following procedures is usually performed to diagnose placenta previa? a. Marlyn is screened for tuberculosis during her first prenatal visit. . Calcium gluconate (Kalcinate) b. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization? a. Aggressive management of a sickle cell crisis includes which of the following measures? a. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Hypertension c. Hypomagnesemia d. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? a. Hemorrhage b. Which of the following drugs is the antidote for magnesium toxicity? a. Emily has gestational diabetes and it is usually managed by which of the following therapy? a. Hydralazine (Apresoline) c. Long-acting insulin c. Diet b. 18 to 22 weeks c. Decreased inspiratory capacity d. Acetaminophen (Tylenol) for pain 93. monoamniotic monochorionic twins 88. Seizure 92. Oral hypoglycemic d. diamniotic monochorionic twin d. diamniotic dichorionic twins c. Decreased oxygen consumption 90. b. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal: a. Amniocentesis b. Diuretic agents c. She is considered to have a positive test for which of the following results? a. Ultrasound 89.

97. small eyes. the nurse John advises a client to assume certain positions and avoid others. b. Urinary tract infection (UTI) 96. Dianne. 2 weeks postpartum. A flattened nose. the nurse Lhynnette expects to find: a. The nurse who's caring for her should stay alert for: a. Asymptomatic bacteriuria b. d. and thin lips. Lateral position b. Pyelonephritis d. Uterine involution d. End of 6th week postpartum. stimulating fetal antibodies. 7th to 9th day postpartum. Which of the following diagnoses is most likely? a. c. Uterine discomfort . Rh-positive fetal blood crosses into maternal blood. a primigravida client. To promote comfort during labor. stimulating maternal antibodies. Which position may cause maternal hypotension and fetal hypoxia? a. Her labor was unusually long and required oxytocin (Pitocin) augmentation. Supine position d. Uterine inversion b. Celeste who used heroin during her pregnancy delivers a neonate. Congenital defects such as limb anomalies. forceps-assisted delivery of twins. 24 year-old is 27 weeks¶ pregnant arrives at her physician¶s office with complaints of fever. stimulating fetal antibodies. and costovertebral angle tenderness. Rh-negative maternal blood crosses into fetal blood. 99. has just completed a difficult. Squatting position c. unilateral flank pain. The uterus returns to the pelvic cavity in which of the following time frames? a. Bacterial vaginosis c. Uterine atony c. nausea. 100. stimulating maternal antibodies. d. Rh-positive maternal blood crosses into fetal blood. b. Standing position 98.95. d. age 20. When the lochia changes to alba. b. c. c. Lethargy 2 days after birth. vomiting. Irritability and poor sucking. Rh-negative fetal blood crosses into maternal blood. Rh isoimmunization in a pregnant client develops during which of the following conditions? a. malaise. When assessing the neonate. Maureen.

6. The nurse should: a. Increasing contractility and slowing heart rate. 8. What are the first nursing actions of the nurse? a. and has been receiving heparin I. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. Provide milk every 2 to 3 hours. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Continue treatment as ordered. because the level is lower than normal. Where the client like 3. c. c. On the client¶s right side b. and check circulation. stabilize spine. and check for hemorrhage. b. for 2 days. Assess level of consciousness and circulation. 7.V. b. and check the pulse. circulation. Decreasing contractility and oxygen consumption. b. d. On the client¶s left side c. In evaluating the effect of nitroglycerin. d. when edema has subsided. b. A client undergone ileostomy. 4. Increase the dosage. Check respirations. c. Increasing AV conduction and heart rate. Make sure that the client takes food and medications at prescribed intervals. The partial thromboplastin time (PTT) is 68 seconds. Stop the I.TEST III . Give two sharp thumps to the precordium. infusion of heparin and notify the physician.Care of Clients with Physiologic and Psychosocial Alterations 1. c. Monitor vital signs every 2 hours. Decreasing venous return through vasodilation. A male client was on warfarin (Coumadin) before admission. d.V. d. check pupils. 5. neurological response. Semiformed 2. when should the drainage appliance be applied to the stoma? a. Green liquid b. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? a. 24 hours later. b. Which is the nurse next action? a. c. Call for help and note the time. Check respiration. When the client is able to begin self-care procedures. . b. Loose. Plan care so the client can receive 8 hours of uninterrupted sleep each night. Administer two quick blows. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is: a. What should Nurse Carla do? a. After the ileostomy begin to function. bloody d. Expect the warfarin to increase the PTT. Clear the airway c. d. Directly in front of the client d. Align the spine. Nurse Arthur should know that it reduces preload and relieves angina by: a. A male client is admitted to the emergency department following an accident. Solid formed c. In the operating room. d.

A 77-year-old male client is admitted for elective knee surgery.While monitoring a male client several hours after a motor vehicle accident. d. c. Which of the following symptoms may appear first? a. On the side.9. she might have which of the following reactions? a. Fever and chills c. Pleuritic chest pain and cough 12. c.V. with the head turned to the side. He recently had a cold. The client is oriented when aroused from sleep. On the back. Chest and lower back pain b. Which of the following symptoms will be exhibit? a. Flat on the stomach. Cruz. Increase in intracranial pressure (ICP). Flat on back. d. b. . 11.Mrs. the client may have which of the following conditions? a. b. She is sleeping and her respiratory rate is 4 breaths/minute. and goes back to sleep immediately. Increased number of functional capillaries in the alveoli c. Decreased residual volume d. to prevent obstruction of airway by tongue. Altered mental status and dehydration b. Chills. with knees flexed 15 degrees. Bronchial pneumonia c. Increased elastic recoil of the lungs b. A male client has active tuberculosis (TB). The client refuses dinner because of anorexia. and hemoptysis c. with an occasional skipped beat. Chronic obstructive pulmonary disease (COPD) d. Decreased vital capacity 16. Nurse John is caring for a male client receiving lidocaine I. Seizure d. Mark. Marichu was given morphine sulfate for pain. Increase in systemic blood pressure. 80 years old is diagnosed with pneumonia. which assessment data suggest increasing intracranial pressure? a. Which of the following is a normal physiologic change related to aging? a. Wake up on his own 15. night sweats. d. He¶s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. Pulse is increased from 87 to 95. Headache and photophobia 13. A client undergone spinal anesthetic. Blood pressure is decreased from 160/90 to 110/70. fever. Respiratory arrest c. Form this history. If action isn¶t taken quickly. it will be important that the nurse immediately position the client in: a. Physical examination reveals shallow respirations but no sign of respiratory distress. a 7-year-old client is brought to the emergency department. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. b. 10. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter. Emphysema 14. Fever of more than 104°F (40°C) and nausea d. Acute asthma b. Hemoptysis and Dyspnea d. Asthma attack b. c. Which factor is the most relevant to administration of this medication? a.

After age 40 d. c.17. the nurse should encourage the client to: a. 24. d. Thoracotomy c. b. Bone fracture b. Nurse Lhynnette is preparing a site for the insertion of an I. 18. Removing the hair with a depilatory. b. Keep rooms brightly lit. George should be taught about testicular examinations during: a. Cystectomy. Nurse Len is teaching a group of women to perform BSE. Cancerous lumps b. Nurse Michelle is caring for an elderly female with osteoporosis. 19. When teaching the client. Laminectomy b. Negative calcium balance d. c. b. These instructions should include which of the following? a. sweating. Avoid foods high in vitamin K c. Provide extra blankets and clothing to keep the client warm. Avoid lifting objects weighing more than 5 lb (2. it is important to: a. and excessive weight loss during thyroid replacement therapy. After age 69 c. Avoiding straining during bowel movement or bending at the waist. Take aspirin to pain relief. Monitor the client for signs of restlessness. To decrease the risk of atherosclerosis. Loss of estrogen c. d. . b. Leaving the hair intact b. The nurse should explain that the purpose of performing the examination is to discover: a. Encourage the client to be active to prevent constipation. Nurse Greta must logroll a client following a: a. when sexual activity starts b. Nurse Kris is teaching a client with history of atherosclerosis. A 55-year old client underwent cataract removal with intraocular lens implant.V. When caring for a female client who is being treated for hyperthyroidism. The nurse should treat excess hair at the site by: a. Follow a regular diet. the nurse should include information about which major complication: a. 23. Fibrocystic masses 21. d. catheter. Increase his activity level. Hemorrhoidectomy d. Avoid focusing on his weight. 22. Changes from previous examinations. Nurse Oliver is giving the client discharge instructions. Shaving the area c. Nurse Ron is caring for a male client taking an anticoagulant. Report incidents of diarrhea. Use a straight razor when shaving. Areas of thickness or fullness c. Balance the client¶s periods of activity and rest. The nurse should teach the client to: a. Continue leading a high-stress lifestyle. Nurse Greta is working on a surgical floor. Lie on your abdomen when in bed c.25 kg). Clipping the hair in the area d. d. Dowager¶s hump 20. d. 25. Before age 20.

Coarse crackles d. Excessive water in the water-seal chamber d. c. A male client undergone a colon resection.Strokes respirations. Place the client on his side. Rapid. b. Excessive chest tube drainage 32. Current health promotion activities. Which information will be most useful to the nurse for planning care? a. The attack is over. Family history of diseases. and insert a bite block. the nurse should: a. Nurse Bea is assessing a male client with heart failure. c. d. While turning him. Rapid.26. Place a saline-soaked sterile dressing on the wound. straddle him. Tracheal b. and hold down his arms. b. The swelling has decreased. a client becomes hypotensive with neck vein distention. remove dangerous objects. Crackles have replaced wheezes. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. The airways are so swollen that no air cannot get through. 31. d. deep breathing with abrupt pauses between each breath. d. and insert a bite block. remove dangerous objects. Friction rubs 29. A progressively deeper breaths followed by shallower breaths with apneic periods. b. wound dehiscence with evisceration occurs. Mike with epilepsy is having a seizure. Shallow breathing with an increased respiratory rate. General health for the last 10 years. Place the client on his side. What cause of tension pneumothorax should the nurse check for? a. Place the client o his back. Nurse Ron is taking a health history of an 84 year old client. Nurse Maureen is talking to a male client. Stay with him but not intervene at this time. c. Call the physician b. The nurse should: a. Nurse Trish first response is to: a. c. b. The client stops wheezing and breath sounds aren¶t audible. Nurse Amanda suspects a tension pneumothorax has occurred. The nurse is caring for Kenneth experiencing an acute asthma attack. the nurse notices Cheyne. tracheal shift. and perform the abdominal thrust maneuver. Cheyne-strokes respirations are: a. Place the client on his back remove dangerous objects. . Take a blood pressure and pulse. Pull the dehiscence closed. The reason for this change is that: a. the client begins choking on his lunch. He¶s coughing forcefully. b. 33. During the active seizure phase. absent breath sounds. c. Leave him to get assistance d. d. During routine assessment. 28. 27. Lay him down. Stand him up and perform the abdominal thrust maneuver from behind. 30. and diaphoresis. remove dangerous objects. Kinked or obstructed chest tube c. After insertion of a cheat tube for a pneumothorax. Marital status. deep breathing and irregular breathing without pauses. c. Infection of the lung. The breath sounds commonly auscultated in clients with heart failure are: a. and protect his head. Fine crackles c. d. b.

4°C) a cough producing yellow sputum and pleuritic chest pain. A 43-yesr-old homeless man with a history of alcoholism d. Which of the following clients entering the clinic today most likely to have TB? a. Oral steroids 39. 35. To determine if a repeat skin test is needed c. peripheral edema and cyanotic nail beds. To determine the extent of lesions d. Apply lemon glycerin to the client¶s lips at least every 2 hours. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away? a. Inhaled steroids d. Tuberculosis 36. The patient is under local anesthesia during the procedure b. The aspiration site is the posterior or anterior iliac crest. Place the client in a side lying position. Brush the teeth with client lying supine. c. The treatment for patients with leukemia is bone marrow transplantation. Adult respiratory distress syndrome (ARDS) b. Myocardial infarction (MI) c. Clean the client¶s mouth with hydrogen peroxide. Nurse Oliver is working in a out patient clinic.34. The nurse suspects this clien may have which of the following conditions? a. Beta-adrenergic blockers b. The nurse is aware that which of the following reasons this is done? a. Based on this information. A 54-year-old businessman 37. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. Virgie with a positive Mantoux test result will be sent for a chest X-ray. he most likely has which of the following conditions? a. The aspirated bone marrow is mixed with heparin. Nurse Krina should: a. A 16-year-old female high school student b. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure. b.V. To confirm the diagnosis b. A 33-year-old day-care worker c. Which statement about bone marrow transplantation is not correct? a. fluids. age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. He¶s being hydrated with L. He has been alerted that there is an outbreak of tuberculosis (TB). When performing oral care on a comatose client. Adult respiratory distress syndrome (ARDS) b. d. c. When the nurse takes his vital signs. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum. . Pneumonia d. To determine if this is a primary or secondary infection 38. d. Asthma c. Chronic obstructive bronchitis d. she notes he has a fever of 103°F (39. 40. Emphysema Situation: Francis. Bronchodilators c. Mr. with the head of the bed lowered.

Nonpalpable right axillary lymph nodes 48. Which of the following is the best initial response by the nurse? a. Benzodiazepines 47. Elevated thrombocyte counts 44. Six hours later.41. a 23-year old client complains of substernal chest pain and states that her heart feels like ³it¶s racing out of the chest´. and a respiratory rate of 22 breaths/ minute. Which assessment finding would strongly suggest that this client's lump is cancerous? a. As the nurse enters the client¶s room to prepare him. Have an abnormally short life span of cells. The 58-year-old client who was admitted 2 days ago with heart failure. Are not responsible for the anemia. Raise the side rails 42. which of the following clients should the on-duty nurse assess first? a. a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. The nurse in-charge first action would be: a. c. ³How can I be anemic if this disease causes increased my white blood cell production?´ The nurse in-charge best response would be that the increased number of white blood cells (WBC) is: a. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L. Call the physician b. The 89-year-old client with end-stage right-sided heart failure. Document the patient¶s status in his charts. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Mobile mass that is soft and easily delineated d. Honey. 43. Nonmobile mass with irregular edges c.V. Robert. Prepare oxygen treatment d. and asks her to prepare the client for surgery. Opioids c. Eversion of the right nipple and mobile mass b. Cocaine d. After several days of admission. She reports no history of cardiac disorders. c. Radiation d. blood pressure of 78/50 mm Hg. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Explain the risks of not having the surgery b. Francis asks the nurse. Predominance of lymhoblasts b.V. b. Immunotherapy . Crowd red blood cells b. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right breast during her monthly self-examination. "What is the usual treatment for this type of cancer?" Which treatment should the nurse name? a. Which of the following drugs should the nurse question the client about using? a. Surgery b. heparin d. During routine care. During the endorsement. Recording the client¶s refusal in the nurses¶ notes 45. and a ³do not resuscitate´ order c. blood pressure of 126/76 mm Hg. Uses nutrients from other cells d. the nurse isn¶t able to obtain pulses in his left foot using Doppler ultrasound. Abnormal blast cells in the bone marrow d. Notifying the nursing supervisor d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L. dilitiazem (Cardizem) 46. The nurse immediately notifies the physician. A 35-year-old client with vaginal cancer asks the nurse. Chemotherapy c. he states that he won¶t have any more surgery. Diagnostic assessment of Francis would probably not reveal: a. Leukocytosis c. Notifying the physician immediately c. Francis becomes disoriented and complains of frequent headaches. Barbiturates b.

Cristina undergoes a biopsy of a suspicious lesion. weight loss. and no evidence of distant metastasis b. Carcinoma in situ. Carcinoma in situ. "Notify a nurse if you experience blood in your urine. which is used to determine protein levels. which is used to screen for prostate cancer. miosis. Can't assess tumor or regional lymph nodes and no evidence of metastasis d. Stool Hematest b. Colon and rectal cancer 52. no abnormal regional lymph nodes. hoarseness and dysphagia. The nurse should reply that it stands for: a. Breast cancer b. b." c. "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis? a. d. both on the affected side. "Keep the stoma uncovered. the nurse should include which instruction? a. and anhidrosis on the affected side of the face. c.49. and fever. "Avoid drinking liquids until the gag reflex returns. No evidence of primary tumor. and ascending degrees of distant metastasis 50. Sigmoidoscopy d. cough. "Remain supine for the time specified by the physician." c. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. 54. chest pain. 53. and no evidence of distant metastasis c. d." 51. "Keep the stoma dry. "Avoid eating milk products for 24 hours. A 37-year-old client with uterine cancer asks the nurse. Lung cancer c." 55. prostate-specific antigen. no demonstrable metastasis of the regional lymph nodes. dyspnea. "Have a family member perform stoma care initially until you get used to the procedure. When assessing for signs and symptoms of this syndrome. Lydia undergoes a laryngectomy to treat laryngeal cancer. arm and shoulder pain and atrophy of arm and hand muscles. Brain cancer d. no abnormal regional lymph nodes. protein serum antigen. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block? a. Which type of cancer causes the most deaths in women? a. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS. partial eyelid ptosis. Papanicolaou-specific antigen. Carcinoembryonic antigen (CEA) c. "Keep the stoma moist." b. When teaching the client how to care for the neck stoma. M0." b. b. Vic asks the nurse what PSA is. c. which is used to screen for cervical cancer. the nurse should note: a. N0. pneumococcal strep antigen." d. What does this classification mean? a. which is a bacteria that causes pneumonia." d. Abdominal computed tomography (CT) scan .

To avoid fractures. White blood cells (WBCs) 58. b. c. The client asks questions. During a breast examination. Loss of muscle contraction decreasing venous return c. Which of the following conditions may cause swelling after a stroke? a. b.56. Septic arthritis b. 50 ml/hour 63. Which finding is a contraindication? a. d. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side d. Joint deformity c. Multiple firm. Which form of arthritis is characterized by urate deposits and joint pain. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. round. Which of the following is one of the most common metastasis sites for cancer cells? a. Which of the following teaching points is correct? a. Liver b. usually in the feet and legs. Bloody discharge from the nipple d. The client wears a watch and wedding band. d. Elbow contracture secondary to spasticity b. Nurse Cecile is teaching a female client about preventing osteoporosis. b. Mr. and occurs primarily in men over age 30? a.000 units of heparin in 500 ml of saline solution. A fixed nodular mass with dimpling of the overlying skin c. The client hears thumping sounds. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. A heparin infusion at 1. freely movable masses that change with the menstrual cycle 57. the nurse reviews the assessment findings for contraindications for this procedure. A 76-year-old male client had a thromboembolic right stroke. which of the following would pose a threat to the client? a. Intermittent arthritis d. Joint flexion of less than 50% d. During the MRI scan. c. 60. Reproductive tract d. Traumatic arthritis c. 59. 15 ml/hour b. Joint pain b. Gouty arthritis 62. The infusion contains 25. 30 ml/hour c. Joint stiffness 61. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. Before Jacob undergoes arthroscopy. Colon c. How many milliliters per hour should be given? a. Hypoalbuminemia due to protein escaping from an inflamed glomerulus . 45 ml/hour d. which finding most strongly suggests that the Luz has breast cancer? a. his left arm is swollen. Rodriguez is admitted with severe pain in the knees. the client should avoid strenuous exercise. The client lies still.500 unit/hour is ordered for a 64-year-old client with stroke in evolution. A female client with cancer is being evaluated for possible metastasis. Slight asymmetry of the breasts.

Which of the following statements is true about a cane or other assistive devices? a. Heberden¶s nodes are a common sign of osteoarthritis.dry dressing change every shift. b. a wetto. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). Osteoarthritis is a localized disease rheumatoid arthritis is systemic c. Parathyroid 70. furosemide (Lasix) c. d. aspirin b. They debride the wound and promote healing by secondary intention. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis? a. They prevent the entrance of microorganisms and minimize wound discomfort. Adrenal medulla d. colchicines d. 21 U regular insulin and 9 U NPH. b. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. Mr.64. and blood glucose monitoring before meals and bedtime. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which of the following glands? a. c. the doctor orders bed rest. rheumatoid arthritis is localized d. c. 68. Which of the following statement is correct about this deformity? a. Mrs. rheumatoid arthritis isn¶t b. It appears on the dorsolateral aspect of the interphalangeal joint. 71. Which laboratory data would the nurse expect to find? a. 10 U regular insulin and 20 U NPH. d. 65. It appears only in men b. The cane should be used on the unaffected side d. For a diabetic male client with a foot ulcer. b. the nurse may give the client: a. Pancreas c. Osteoarthritis has dislocations and subluxations. There is no 70/30 insulin available. Hypernatremia d. Why are wet-to-dry dressings used for this client? a. 20 U regular insulin and 10 U NPH. The cane should be used on the affected side c. Cruz uses a cane for assistance in walking. rheumatoid arthritis doesn¶t 66. Hyperglycemia . As a substitution. Osteoarthritis is gender-specific. It appears on the proximal interphalangeal joint d. A walker is a better choice than a cane. calcium gluconate (Kalcinate) 69. A client with osteoarthritis should be encouraged to ambulate without the cane 67. Hyperkalemia b. They protect the wound from mechanical trauma and promote healing. It appears on the distal interphalangeal joint c. Osteoarthritis is a systemic disease. Reduced blood urea nitrogen (BUN) c. Nurse Zeny is caring for a client in acute addisonian crisis. Nurse Len should expect to administer which medication to a client with gout? a. Adrenal cortex b. They contain exudate and provide a moist wound environment. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism.

Alkaline phosphatase level d. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer? a. Hypocalcemia b. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a. 10:00 am b. the client reports numbness and tingling of the mouth and fingertips. serum fructosamine level. vomiting. Noon c. and diarrhea b.V. To determine the effectiveness of the client's efforts. 4:00 pm d. Which nursing intervention is appropriate? a. the nurse should check: a. urine glucose level. Restricting fluids d. The baby can get the virus from my placenta." d. tachycardia. Francis with anemia has been admitted to the medical-surgical unit.V. glycosylated hemoglobin level. Acid phosphatase level b. Proserfina exhibits muscle twitching and hyperirritability of the nervous system. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. On the third day after a partial thyroidectomy. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH)." c." b. Hypermagnesemia 77. Infusing I.m. Serum calcitonin level c. In teaching a female client who is HIV-positive about pregnancy. the nurse would know more teaching is necessary when the client says: a. Nausea. Catecholamines and epinephrine c. Dyspnea. "I'll need to have a C-section if I become pregnant and have a baby." . rash. Administering glucose-containing I. Which assessment findings are characteristic of iron-deficiency anemia? a. Itching. Norepinephrine and epinephrine 76. Suspecting a lifethreatening electrolyte disturbance. 74. 10:00 pm 75. Glucocorticoids and androgens b. Hyponatremia c. Carcinoembryonic antigen level 78. fluids rapidly as ordered b. b. fluids as ordered 73. fasting blood glucose level. Mineralocorticoids and catecholamines d. the nurse notifies the surgeon immediately. The adrenal cortex is responsible for producing which substances? a. c. "I'm planning on starting on birth control pills. Encouraging increased oral intake c. "Not everyone who has the virus gives birth to a baby who has the virus. and jaundice 79. Hyperkalemia d. and pallor c. Nights sweats.72. Which electrolyte disturbance most commonly follows thyroid surgery? a. When questioned. d. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction? a. and anorexia d. weight loss.

To confirm that the client has been infected with the human immunodeficiency virus (HIV). Mathew develops abdominal pain. nutritional supplementation. d. c. fever. Monocyte d. d. and a 20-lb weight loss in 6 weeks. In an individual with Sjogren's syndrome. the nurse discusses adverse reactions to prolonged aspirin therapy. These include: a. . d. dyspnea." 81." b. Lymphocyte 85. Administer epinephrine. c. moisture replacement. Page an anesthesiologist immediately and prepare to intubate the client. double vision. Administer the antidote for penicillin. Angina. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation.V. 84. Which set of findings should the nurse expect when assessing the client? a. weight gain. fluids as ordered. 83. b. the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). b. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home. bradycardia.80. enzyme-linked immunosorbent assay (ELISA). When teaching the client about the immune system. "Sterilize all plates and utensils in boiling water. nursing care should focus on: a. and continue to monitor the client's vital signs. fine motor tremors. electrolyte panel and hemogram. respiratory acidosis. and "horse barn" smelling diarrhea. the nurse expects the physician to order: a. the nurse states that adaptive immunity is provided by which type of white blood cell? a. and anorexia 82. and a sore tongue c. c. "Avoid eating foods from serving dishes shared by other family members. and prepare to intubate the client if necessary. Nurse Celestina suspects the client is experiencing anaphylactic shock. arrhythmia management. d. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). stool for Clostridium difficile test. quantification of T-lymphocytes. night sweats. "Avoid sharing such articles as toothbrushes and razors. b. Basophil c. bilateral hearing loss. and reduced pulse pressure b. Sore tongue. After receiving a dose of penicillin. Neutrophil b. flat plate X-ray of the abdomen. d. It would be most important for the nurse to advise the physician to order: a. When teaching the client about aspirin. c. electrolyte balance. A male client seeks medical evaluation for fatigue. and weight gain d. b. After recovering from the initial shock of the diagnosis. a client develops dyspnea and hypotension. 87. Mr. Insert an indwelling urinary catheter and begin to infuse I. b. the nurse should be sure to include which instruction? a. as prescribed. Western blot test with ELISA. What should the nurse do first? a. enzyme-linked immunosuppressant assay (ELISA) test. tachycardia. Pallor." c." d. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Pallor. c. 86. E-rosette immunofluorescence. During chemotherapy for lymphocytic leukemia. as prescribed. "Put on disposable gloves before bathing.

Platelet count. oral temperature 99 degrees Fahrenheit. c. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels b. the nurse should take which of the following actions? a. b. Platelet count. Blood pressure 138/82. ³My arms and legs are itching. and white blood cell (WBC) count c. A complete blood count is commonly performed before a Joe goes into surgery. A 62-year-old who had an abdominal-perineal resection three days ago. Low levels of urine constituents normally excreted in the urine c. The client supports his head and neck when turning his head to the right. Which of the following clients should the nurse see first? a. no drainage noted in the previous eight hours. d. When taking a dietary history from a newly admitted female client. Orange d. Administer Demerol 50 mg IM q 4 hours and PRN. c. blood glucose levels.´ b. d.88. calcium levels. Electrolyte imbalance that could affect the blood's ability to coagulate properly 89. 1. A client with hepatitis A who states. A client with osteomyelitis of the spine who states. the nurse should take note of what assessment parameters? a.5 cm area of dark drainage noted on the dressing. A 59-year-old with a collapsed lung due to an accident. Fibrinogen level. Thrombin time. ³I am so nauseous that I can¶t eat. The client is drowsy and complains of sore throat. Encourage the client to change positions frequently in bed. Which of the following phone calls should the nurse return first? a. To assist with pain relief. b. A client with rheumatoid arthritis who states. respirations 16.´ c. client complaints of chills. ³I am having trouble sleeping. While monitoring a client for the development of disseminated intravascular coagulation (DIC). 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain. and partial thromboplastin time b. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. The nurse would be most concerned if which of the following was observed? a. ³I have a funny feeling in my right leg. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels d. . Apply warmth to the abdomen with a heating pad.´ d. The client spontaneously flexes his wrist when the blood pressure is obtained. Bread b. A 35-year-old admitted three hours ago with a gunshot wound. prothrombin time. Carrots c. Strawberries 91. c. and potassium levels d. d. b. Nurse John is caring for clients in the outpatient clinic. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave¶s disease. 94. Nurse Len should remember that which of the following foods is a common allergen? a. and platelet count 90. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. A client with cast on the right leg who states. A 43-year-old who had a mastectomy two days ago.´ 92. 93. Use comfort measures and pillows to position the client. What does this test seek to identify? a. WBC.

and then takes several small steps forward. and gustatory abilities. Decrease musculoskeletal function and mobility. Insert a Foley catheter 96. Position the client on the left side. The client slides the walker 18 inches forward. Select a room with a bed by the door so the woman can look down the hall. Suggest the woman eat her meals in the room with her roommate. and then moves the right leg. Which of the following actions. Increased sensitivity to the side effects of medications. auditory. and then moves the left leg. d. Check the client¶s temperature. moves the cane forward followed by his left leg. then takes small steps while holding onto the walker for balance. is most appropriate? a. b. indicates that the nurse¶s teaching was effective? a. What step should nurse Jasmine take next? a. and then moves the right leg. moves it forward 10 inches. The client supports his weight on the walker while advancing it forward. d. then takes small steps forward while leaning on the walker. Encourage the woman to ambulate in the halls twice a day. Assess for a bruit and a thrill. 99. indicates that the teaching was effective? a. The client is occasionally confused and her gait is often unsteady. The client holds the cane with his left hand. b. d. c. The client holds the cane with his right hand. c.95. moves the cane forward followed by the right leg. Which of the following actions should the nurse take first? a. A male client with emphysema becomes restless and confused. The client slowly pushes the walker forward 12 inches. Nurse Tina prepares a client for peritoneal dialysis. 98. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason? a. 100. then takes small steps while balancing on the walker. Increase the client¶s oxygen flow rate. moves the can forward followed by the right leg. The client lifts the walker. d. c. moves the cane forward followed by his left leg. b. Decreased visual. if demonstrated by the client. Which of the following behaviors. Nurse Deric is supervising a group of elderly clients in a residential home setting. if taken by the nurse. Assess the client¶s potassium level. Warm the dialysate solution. b. d. Which of the following behaviors. The client holds the cane with his right hand. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Ask the woman¶s family to provide personal items such as photos or mementos. . b. c. c. if demonstrated by the client to the nurse. b. An elderly client is admitted to the nursing home setting. Encourage the client to perform pursed lip breathing. Isolation from their families and familiar surroundings. The client holds the cane with his left hand. and then moves the left leg. c. 97. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. d.

As part of the prescribed therapy to correct this electrolyte imbalance. Randy has undergone kidney transplant. Decrease the total basal metabolic rate. Liver disease b. ³I should: a. Administer Kayexalate b.V. Administer large amounts of normal saline via I. with recent colostomy expresses concern about the inability to control the passage of gas. Sudden weight loss b. Polycythemia 6. Leukopenia d. Polyuria c. 7. The nurse would evaluate that the instructions were understood when the client states. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. c. The immediate objective of nursing care for an overweight. The nurse is aware that this medication is given to: a. Block the formation of thyroxine by the thyroid gland.´ c. Avoid foods that in the past caused flatus. Nystagmus c. b. the nurse would expect to: a.´ 8. Hematuria d. Pain b. with hyperthyroidism is to receive Lugol¶s iodine solution before a subtotal thyroidectomy is performed. The client is somewhat confused and complains of nausea and muscle weakness. what assessment would prompt Nurse Katrina to suspect organ rejection? a. Norma. Type 2 diabetes d. b. Keep the irrigating container less than 18 inches above the stoma. Ricardo. mildly hypertensive male client with ureteral colic and hematuria is to decrease: a. d.´ d. . The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with: a. d. Adhere to a bland diet prior to social events. Hyperthyroidism 5. Weight c. Maintain the function of the parathyroid glands. Nurse Oliver should suggest that the client plan to: a. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure. was diagnosed with type I diabetes.´ b. Hypertension d. Eliminate foods high in cellulose. Decrease fluid intake at meal times. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel. Ascites b. Shock 2. Hypertension c. 4.TEST IV . Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Increase oral intake of cheese and milk. Nurse Ron begins to teach a male client how to perform colostomy irrigations. Lie on my left side while instilling the irrigating solution. Restrict foods high in protein c. c. Decrease the size and vascularity of the thyroid gland. Hypertension 3. d.Care of Clients with Physiologic and Psychosocial Alterations 1. Matilda. Nurse Ruby should monitor the client for the systemic side effect of: a.

In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. Right upper arm and penis c. May engage in contact sports 13. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. b. Herbert. c. b. take the pulse rate once a day. 32 gtt/min d. b. and sodium bicarbonate to be used to treat: a. c. . When teaching Kristine what to expect afterward. which has the largest percent of burns? a. hypokalemia. hypercalcemia. 16. The drop factor of the tubing is 10 gtt/ml. Food and fluids will be withheld for at least 2 hours. Facilitate ventilation of the left lung. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. d. Coughing and deep-breathing exercises will be done q2h. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? a. Bleeding from ears d.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. c. The nurse should set the flow to provide: a. Only ice chips and cold liquids will be allowed initially. Using the rule of nines. 28 gtt/min c. After Forty48 hours. Reduce incisional pain. Have regular follow up care d.Nurse Tristan is caring for a male client in acute renal failure. Mario has burn injury. and one-bottle water-seal drainage is instituted in the operating room. The nurse is aware that this position: a. c. 18 gtt/min b. An elevated temperature 12. Reactive pupils b. hypernatremia. hyperkalemia.9. Upper trunk 11. a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. d. 14. b. Increase venous return 15. Blood gases are monitored using a pulse oximeter. Warm saline gargles will be done q 2h. Face and neck b. d. in the morning upon awakening b. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.Kristine is scheduled for a bronchoscopy. Right thigh and penis d. insulin infusions.Terence suffered form burn injury. Equalize pressure in the pleural space. A depressed fontanel c. Oxygen is administered best using a non-rebreathing mask d. the nurse would be most concerned if the assessment revealed: a. When assessing the client. 36 gtt/min 10.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is a. Chest tubes are inserted. The nurse should expect hypertonic glucose. the physician orders for Mario 2 liters of IV fluid to be administered q12 h. May be allowed to use electrical appliances c. the nurse's highest priority of information would be: a.

When palpating the her kidneys. d. c. Katrina asks what dysplasia means. The kidneys are situated just above the adrenal glands. 21. b. ." to 1-1/8") wide. Multiple myeloma c. The human papillomavirus (HPV). magnesium. Increased pH with decreased hydrogen ions. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. 20.Ms. Katrina has an abnormal result on a Papanicolaou test. b. What is the most common AIDS-related cancer? a. To prevent confusion b. d.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. b. which should eradicate the problem within 7 to 10 days. the nurse should keep which anatomical fact in mind? a. Alteration in the size. To prevent seizures c. 19. Auscultate bowel sounds.17. 18. In the operating room. which causes condylomata acuminata. Increased serum levels of potassium. therefore. The most common treatment is metronidazole (Flagyl). The average kidney is approximately 5 cm (2") long and 2 to 3 cm (. X has just been diagnosed with condylomata acuminata (genital warts).5 mg/ dl.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%. and organization of differentiated cells. The kidneys lie between the 10th and 12th thoracic vertebrae. c. d. the nurse positions the client according to the anesthesiologist's instructions.Ricardo is scheduled for a prostatectomy. and calcium. To prevent cerebrospinal fluid (CSF) leakage d. This condition puts her at a higher risk for cervical cancer. and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. Which definition should the nurse provide? a. b. Insert a rectal tube. To prevent cardiac arrhythmias 23. Palpate the abdomen. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found. c. Why does the client require special positioning for this type of anesthesia? a. Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin. d. b. Uric acid analysis 3. The left kidney usually is slightly higher than the right one. After admitting that she read her chart while the nurse was out of the room. Change the client's position. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. The nurse is aware that the diagnostic test are consistent with CRF if the result is: a. Kaposi's sarcoma 22. What information is appropriate to tell this client? a. Leukemia d. c. d. During a routine checkup. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6. The first nursing action should be to: a. she should have a Papanicolaou (Pap) smear annually.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. Squamous cell carcinoma b. c. can't be transmitted during oral sex. shape.Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department.

Perform passive range-of-motion (ROM) exercises. An intestinal obstruction has occurred. and downward strokes in the direction of hair growth d.A male client with inflammatory bowel disease undergoes an ileostomy.24. 29. to enhance absorption. b. With a circular motion. and chest. b. Lying on the left side with knees bent c.Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. Lying on the right side with legs straight b. Calcium channel blocker c. Encourage the client to use a footboard. With an upward motion. In long. To help the client avoid pressure ulcers. b. even. Applying knee splints b. Raised 30 degrees d. Turn him frequently. 26. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. On the first day after surgery. Hyperextending the client's palms d. Raised 10 degrees c. d. Bent over with hands touching the floor 25. Nitrates 31.Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is: a.Nurse Ron is assessing a client admitted with second. even. c. How should the nurse interpret this finding? a. How should the nurse apply this topical agent? a.A male client has jugular distention. White pulmonary secretions. Nurse Celia should: a. to increase blood supply to the affected area c. Performing shoulder range-of-motion exercises 27. How should the nurse Patricia position the client for this test initially? a. Urine output of 20 ml/hour.and third-degree burns on the face. The ostomy bag should be adjusted. In long. and upward strokes in the direction opposite hair growth 30. Rectal temperature of 100. d. d. which nursing intervention helps prevent contractures? a. outward. Blood supply to the stoma has been interrupted. Supine position . arms. Reduce the client's fluid intake. Prone with the torso elevated d. b. 28. c. outward. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. c. Mr. This is a normal finding 1 day after surgery. Narcotics d. Nurse Oliver notes that the client's stoma appears dusky. Beta -adrenergic blockers b. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention? a.Anthony suffers burns on the legs. High Fowler¶s b. Which finding indicates a potential problem? a.6° F (38° C). Elevating the foot of the bed c.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy.

32.The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? a. Beta-adrenergic blockers b. Calcium channel blocker c. Diuretics d. Inotropic agents

33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client? a. Fiber intake of 25 to 30 g daily b. Less than 30% of calories form fat c. Cholesterol intake of less than 300 mg daily d. Less than 10% of calories from saturated fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality? a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit b. The CCU nurse notifies the on-call physician about a change in the client¶s condition c. The emergency department nurse calls up the latest electrocardiogram results to check the client¶s progress. d. At the client¶s request, the CCU nurse updates the client¶s wife on his condition 35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client¶s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first? a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes. b. Check endotracheal tube placement. c. Obtain an arterial blood gas (ABG) sample. d. Administer atropine, 1 mg L.V. 36. After cardiac surgery, a client¶s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following? a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate? a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values. c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel 38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted? a. Pancytopenia b. Idiopathic thrombocytopemic purpura (ITP) c. Disseminated intravascular coagulation (DIC) d. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)? a. Acetylsalicylic acid (ASA) b. Corticosteroids c. Methotrezate d. Vitamin K

40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this? a. Allogeneic b. Autologous c. Syngeneic d. Xenogeneic

41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway? a. Release of Calcium b. Release of tissue thromboplastin c. Conversion of factors XII to factor XIIa d. Conversion of factor VIII to factor VIIIa

42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias? a. Dressler¶s syndrome b. Polycythemia c. Essential thrombocytopenia d. Von Willebrand¶s disease

43. The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin¶s disease? a. Pericarditis b. Night sweat c. Splenomegaly d. Persistent hypothermia

44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed? a. Blood pressure b. Bowel sounds c. Heart sounds d. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system? a. Brain b. Muscle spasm c. Renal dysfunction d. Myocardial irritability

46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)? a. Less than 5 years b. 5 to 7 years c. 10 years d. More than 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC? a. Low platelet count b. Elevated fibrinogen levels c. Low levels of fibrin degradation products d. Reduced prothrombin time

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis? a. Influenza b. Sickle cell anemia c. Leukemia d. Hodgkin¶s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? a. AB Rh-positive b. A Rh-positive c. A Rh-negative d. O Rh-positive

Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. 50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy¶s mother indicated that she understands when she will contact the physician? a. ³I should contact the physician if Stacy has difficulty in sleeping´. b. ³I will call my doctor if Stacy has persistent vomiting and diarrhea´. c. ³My physician should be called if Stacy is irritable and unhappy´. d. ³Should Stacy have continued hair loss, I need to call the doctor´. 51. Stacy¶s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is: a. ³Stacy looks very nice wearing a hat´. b. ³You should not worry about her hair, just be glad that she is alive´. c. ³Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset´. d. ³This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture´. 52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should: a. Provide frequent mouthwash with normal saline. b. Apply viscous Lidocaine to oral ulcers as needed. c. Use lemon glycerine swabs every 2 hours. d. Rinse mouth with Hydrogen Peroxide. 53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is: a. Notify the physician b. Flush the IV line with saline solution c. Immediately discontinue the infusion d. Apply an ice pack to the site, followed by warm compress. 54. The term ³blue bloater´ refers to a male client which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema

55. The term ³pink puffer´ refers to the female client with which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema

56. 80 mm Hg 57. Increased urine output b. Nurse Oliver would expect the paco2 to be which of the following values? a. Gonzales develops hepatic encephalopathy. decreased blood pressure. Mr. 30 mm Hg c. 63. she develops chest tightness and becomes short of breath and tachypneic. every 2 hours. Lower back pain. decreased RBC count. Asthma attack b. HCO324mEq/L. Decreased serum acid phosphate level c. Intermitted lower back pain. Severe lower back pain. decreased RBC count. Altered level of consciousness c. . increased blood pressure. Rheumatoid arthritis Situation: Mr. Inadequate nutrition d. Hypotension 62. Varix formation c. ³I¶ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day´. increased white blood (WBC) count. Respiratory acidosis a. Which laboratory test indicates liver cirrhosis? a. Gonzales regained consciousness. Decreased tendon reflex d. The nurse best action would be: a. Pulmonary embolism c. She has a decreased level of consciousness. Mr. To rule out cirrhosis of the liver: 59. c. decreased RBC count.o. ³Maybe your reacting to the drug. Elevated white blood cell count d. decreased blood pressure. Respirator y alkalosis b. the physician orders 50 ml of Lactose p. Thirty minutes after she takes the drug. When Mr. Norma has started a new drug for hypertension. Impaired clotting mechanism b. 40 mm Hg d. Timothy¶s arterial blood gas (ABG) results are as follows. Which clinical manifestation is most common with this condition? a. Trauma of invasive procedure 61. b.The biopsy of Mr. decreased WBC count.16. pH 7. ³Frequently. increased WBC count. c. Metabolic alkalosis 58. Mr. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. Sao2 81%. Gonzales was admitted to the hospital with ascites and jaundice. Gonzales is at increased risk for excessive bleeding primarily because of: a. Paco2 80 mm Hg. bowel movements are needed to reduce sodium level´. b. Decreased red blood cell count b. Metabolic acidosis d. An arterial blood gas value is obtained. 15 mm Hg b. I will withhold the next dose´. Elevated serum aminotransferase 60. Gonzales confirms the diagnosis of cirrhosis. d. increased WBC count. These signs indicate which of the following conditions? a. Severe lower back pain. ³I¶ll see if your physician is in the hospital´. This ABG result represents which of the following conditions? c. decreased blood pressure. d. Pao2 46 mm Hg. decreased re blood cell (RBC) count. decreased RBC count. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm? a. Gozales develops diarrhea. Respiratory failure d.

elevated antinuclear antibody (ANA) titer d. Percutaneous transluminal coronary angioplasty (PTCA) 66. When offered acetaminophen. b. Call for help.´ c. It dilates peripheral blood vessels. Myocardial infarction (MI) 67. c. It inhibits the angiotensin-coverting enzymes d.´ b.´ . Nitroglycerin d. Kidneys¶ excretion to sodium only. b. Echocardiogram c. Leukocysis. Apply gloves and assess the groin site 65. Which of the following steps should the nurse take first? a. Kidneys¶ retention of sodium and excretion of water 68. Elavated serum complement level b.´ d. Obtain vital signs c. ³Your son had a mild concussion. Distributive shock d. which increases the intracarnial pressure (ICP). a 19-year-old client with a mild concussion is discharged from the emergency department. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is: a. Ask the client to ³lift up´ d. Cardiac catheterization b. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is: a. Arnold. elevated sedimentation rate c. Cardiogenic shock c. Which of the following treatment is a suitable surgical intervention for a client with unstable angina? a. he complains of a headache. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels? a. his mother tells the nurse the headache is severe and she would like her son to have something stronger. 69. ³Narcotics are avoided after a head injury because they may hide a worsening condition. elevated blood urea nitrogen (BUN) and creatinine levels 70. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is: a. Anaphylactic shock b. After undergoing a cardiac catheterization. acetaminophen is strong enough. Kidneys¶ excretion of sodium and water d. Tracy has a large puddle of blood under his buttocks.64. Stronger medications may lead to vomiting. It inhibits reabsorption of sodium and water in the loop of Henle. It decreases sympathetic cardioacceleration. ³Aspirin is avoided because of the danger of Reye¶s syndrome in children or young adults. Kidneys¶ retention of sodium and water c. Which of the following responses by the nurse is appropriate? a. b. Before discharge. Pancytopenia. Thrombocytosis.

Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. Dry mucous membranes d. the client's urine output suddenly rises above 200 ml/hour. Which laboratory findings support the nurse's suspicion of diabetes insipidus? a. Which of the following actions of colchicines explains why it¶s effective for gout? a. Thyroid storm c. above-normal serum osmolality level . Below-normal urine and serum osmolality levels c. Which of the following statements about osteoarthritis is correct? a. Significant. Decreases infection c. Decreases inflammation d. Below-normal urine osmolality level. Frequent urination 77. the nurse notes the Paco2 is 30 mm Hg. Nurse Sugar is assessing a client with Cushing's syndrome. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications? a. the client has alveolar hypoventilation 72. Decreases bone demineralization 74. Which of the following responses best describes the result? a. When prioritizing care. Above-normal urine and serum osmolality levels b. A 17-year-old clients 24-hours postappendectomy b. Appropriate. Osteoarthritis is rarely debilitating b. which of the following clients should the nurse Olivia assess first? a. When evaluating an arterial blood gas from a male client with a subdural hematoma. the client is poorly oxygenated c. Which observation should the nurse report to the physician immediately? a.71. A 50-year-old client with diverticulitis 73. Osteoarthritis afflicts people over 60 75. Pitting edema of the legs b. leading the nurse to suspect diabetes insipidus. Replaces estrogen b. below-normal serum osmolality level d. Tibial myxedema 76. Emergent. Exophthalmos b. Thirty-six hours later. Norma asks for information about osteoarthritis. Osteoarthritis is a rare form of arthritis c. Myxedema coma d. Above-normal urine osmolality level. Osteoarthritis is the most common form of arthritis d. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome c. Normal d. A 50-year-old client 3 days postmyocardial infarction d. An irregular apical pulse c. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout.

Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropinsecreting pituitary adenoma? a. I'll eat a snack high in carbohydrates.m. Testing urine specific gravity c. which of the following statements indicates that the client understands her condition and how to control it? a.. High corticotropin and low cortisol levels b. Hyperparathyroidism 80.m. I should drink a glass of soda that contains sugar. right after I wake up. Based on these assessment findings. the nurse would suspect which of the following disorders? a. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay . Diabetes mellitus b. A decreased TSH level c. depression. Checking temperature every 4 hours d. Which statement by the client indicates an understanding of the instructions? a. 84. onset to be at 2 p. Insulin is administered using a scale of regular insulin according to glucose results. weakness. Low corticotropin and high cortisol levels c. At 2 p. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder.. onset to be at 4 p. "If I experience trembling. and bone pain that interferes with her going outdoors. "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated. Testing for ketones in the urine b. Diabetes insipidus c. and headache. and its peak to be at 3 p. Hypoparathyroidism d.m. drink. Low corticotropin and low cortisol levels 82." 79. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon. Nurse Mariner should expect the dose's: a. the nurse should assess for potential complications by doing which of the following? a. and its peak to be at 3 p. Preoperatively. and its peak to be at 6 p. onset to be at 2:15 p.m. onset to be at 2:30 p. or eat more than usual. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test b. When preparing the client for discharge and home management. Performing capillary glucose testing every 4 hours 83.m. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. An increase in the TSH level after 30 minutes during the TSH stimulation test d. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. "I'll take the entire dose at bedtime." b." c." 81." b. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. d.78." d. increased urination. "I'll take all of my hydrocortisone in the morning. b. "I'll take my hydrocortisone in the late afternoon. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home." c. A 66-year-old client has been complaining of sleeping more. and its peak to be at 4 p. before dinner. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate. anorexia. weakness.m. c. "If I begin to feel especially hungry and thirsty.m. the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Which test result would confirm the diagnosis? a. High corticotropin and high cortisol levels d." d.m.m. irritability.

Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Potassium and sodium 90. Placing extra blankets on the client's bed c. "Administer insulin into sites above muscles that you plan to exercise heavily later that day." b. Spontaneous pneumothorax . "Inject insulin into healthy tissue with large blood vessels and nerves." c." d. Serum ketone bodies c. Fracture of the humerus d. Maintaining room temperature in the low-normal range 88. For a client with Graves' disease. Cleo is diagnosed with osteoporosis. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. "Rotate injection sites within the same anatomic region. What is a Colles' fracture? a. Phosphorous and potassium d. Rico with diabetes mellitus must learn how to self-administer insulin. Bronchitis d. requiring intubation and mechanical ventilation." 86. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? a. Asthma attack b. Pneumonia d. Restricting intake of oral fluids b. A client with shortness of breath has decreased to absent breath sounds o the right side. Adult respiratory distress syndrome (ARDS) b. Fracture of the distal radius b. Bronchitis d. Below-normal serum potassium level 87. Chronic bronchitis c. Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. Atelectasis c. Pneumonia 91. the nurse should provide which instruction? a. Fracture of the carpal scaphoid 89. When teaching the client how to select and rotate insulin injection sites.85. Limiting intake of high-carbohydrate foods d. Atelectasis c. Fracture of the olecranon c. Calcium and phosphorous c. Which other laboratory finding should the nurse anticipate? a. He develops severe hypoxia 48 hours after the incident. Which of the following conditions would best explain this? a. Which electrolytes are involved in the development of this disorder? a. from the apex to the base. Fat embolism 92. He most likely has developed which of the following conditions? a. Acute asthma b. Serum alkalosis d. which nursing intervention promotes comfort? a. The physician has prescribed 10 U of U 100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. "Administer insulin into areas of scar tissue or hypotrophy whenever possible. not among different regions. Calcium and sodium b. Elevated serum acetone level b.

³I should wear the stockings even when I am sleep. Mickey. what fills the area of the thoracic cavity? a. Digoxin (lanoxin) 0. 2. The IV infusion set has a drop factor of 10 drops per milliliter.12 mg is ordered for the child. Respiratory acidosis d. The acid-base disorder that may be present is? a.4 ml c. He¶s now in the emergency department complaining of difficulty of breathing and chest pain. a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. This client may have which of the following conditions? a. ³I should put on the stockings before getting out of bed in the morning. Alveolar damage in the infracted area b. Inadequate suction d. Tuberculosis (TB) 94. 4. Pneumonia c.000 ml of Ringer¶s lactate solution IV to run over 24 hours. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. Nurse Michelle calculates the IV flow rate for a postoperative client. 35 d. After a motor vehicle accident. 1.´ b. Nurse Alexandra teaches a client about elastic stockings. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. 21 c. Air leak b. Armand an 22-year-old client is admitted with a pneumothorax. no breath sounds are present in the upper lobe. Involvement of major blood vessels in the occluded area c. 18 b. The surgeon inserts a chest tube and attaches it to a chest drainage system. Metabolic alkalosis c.2 ml b. Loss of lung parenchyma d. Pneumothorax d.´ c. The client receives 3. The bottle of Lanoxin contains . On auscultation of his lung field.93. If a client requires a pneumonectomy. Which of the following is the most likely cause of the bubbling? a. if made by the client. Bubbling soon appears in the water seal chamber. Bronchitis b. Kinked chest tube 98.5 ml d. indicates to the nurse that the teaching was successful? a.´ . Adequate suction c. Loss of lung tissue 96. Respiratory alkalosis 97. The space remains filled with air only b. 3. The surgeon fills the space with a gel c. What amount should the nurse administer to the child? a. ³Every four hours I should remove the stockings for a half hour.05 mg of Lanoxin in 1 ml of solution. The nurse should regulate the client¶s IV to deliver how many drops per minute? a. Serous fluids fills the space and consolidates the region d.´ d.2 ml 100. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons? a. Metabolic acidosis b. ³I will wear the stockings until the physician tells me to remove them. The tissue from the other lung grows over to the other side 95. Which of the following statements. 40 99.

The mother says that she is afraid of what the father might say to the boy. The adolescent denies stealing. but not yet on medication. it was all right to borrow them. Agree to talk with the mother and the father together. Tina who is manic. The client needs to be on medication first. Exploring d. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? a. Remove all other clients from the dayroom. not being able to sleep at night. The client is harmful to others. Dervid. Focusing 2. Nurse John responds to the client. b. d. but now complains that it ³doesn¶t help´ and refuses to take it. Id b. and feeling upset with his wife. rationalizing instead that as long as no one was using the items. The client is disruptive. Tony refuses his evening dose of Haloperidol (Haldol). He begins cursing and throwing furniture. this behavior may be largely attributed to a developmental defect related to the: a. c. Observations b. Ego c. Check the client¶s medical record for an order for an as-needed I. 3. Suggest that it takes awhile before seeing the results. d. Record the client¶s response. The client¶s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. 7. comes to the drug treatment center. b. Withhold the drug.M. Encourage the client to tell the doctor. Superego d. an adolescent has a history of truancy from school. 6. Impending coma. Dervid. It is important for the nurse to understand the psychodynamically. Marquez reports of losing his job. Suggest that the father and son work things out. Place the client in full leather restraints. Restating c. The client is harmful to self. Perceptual disorders. c. then becomes extremely agitated in the dayroom while other clients are watching television. b. an adolescent boy was admitted for substance abuse and hallucinations. ³You may want to talk about your employment situation in group today. running away from home and ³barrowing´ other people¶s things without their permission. Oedipal complex . d.NURSING PRACTICE V Care of Clients with Physiologic and Psychosocial Alterations 1. dose of medication for agitation. Recent alcohol intake. Nurse Oliver first action is to: a. Depression with mutism. Refer the mother to the hospital social worker. c. Mr. c. b. 5. 4. b. c. Call the attending physician and report the behavior. d. The most appropriate nursing intervention would be to: a. Inform the mother that she and the father can work through this problem themselves. Aira has taken amitriptyline HCL (Elavil) for 3 days. d. The nurse would not let this client join the group session because: a. What should the nurse say or do? a.´ The Nurse is using which therapeutic technique? a.

Increase calories.Meryl. By designating times during which the client can focus on the behavior. Which nursing intervention is most appropriate for Ruby? a. b. chlordiazepoxide (Librium) and diazepam (Valium) c. How should the nurse respond to this compulsive behavior? a. Ruby returns to the clinic. not physical. Ignoring the child. c. Analgesia. 12. c. Short-acting anesthesia b. "You've developed this paralysis so you can stay with your parents.8. loss of control. and apple slices." b.After seeking help at an outpatient mental health clinic. Give the client pieces of cut-up steak. is highly dependent on her parents and fears leaving home to go away to college. You must deal with this conflict if you want to walk again. Exploring the meaning of the traumatic event with the client. Allowing the client time to heal. Increase calories. as prescribed.Nurse Krina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD): a. By discouraging the client from verbalizing anxieties. carrots. d. Meryl asks the nurse. decrease fat. We'll work on what is going on in your life to find out why it's happened. d. fluvoxamine (Luvox) and clomipramine (Anafranil) d. Decreased oral and respiratory secretions." c. complaining of fear. low-fat diet. "Your problem is real but there is no physical basis for it. 13. c. Acting overly solicitous toward the child. c. d." d. d. Serve the client a bowl of soup. By urging the client to reduce the frequency of the behavior as rapidly as possible. You may feel better if you realize the problem is psychological. By calling attention to or attempting to prevent the behavior. 11.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. Flat affect b. and an apple. Shortly before the semester starts. 10. Skeletal muscle paralysis. buttered French bread. "Why has this happened to me?" What is the nurse's best response? a. Recommending a high-protein. b. Giving sleep medication. carbohydrates. to restore a normal sleepwake cycle. benztropine (Cogentin) and diphenhydramine (Benadryl). Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is: a. Three months later. 9. d. When physical examination rules out a physical cause for her paralysis.What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse? a. "It isn't uncommon for someone with your personality to develop a conversion disorder during times of stress." 14. "It must be awful not to be able to move your legs. she complains that her legs are paralyzed and is rushed to the emergency department. and helpless feelings. Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). b. the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. divalproex (Depakote) and lithium (Lithobid) . b. and protein. In preparing a female client for electroconvulsive therapy (ECT). Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect? a. and decrease protein. age 19. Expressing guilt c.

what is its onset of action? a. Providing emotional support and individual counseling. sweating. Agitation. Nurse Patricia should plan to focus this client's care on: a.Alfred was newly diagnosed with anxiety disorder. History of gainful employment b. b. stable relationships d.Richard with agoraphobia has been symptom-free for 4 months. When this drug is used to treat atypical depression. c. c. Insomnia and an inability to concentrate. b. d. d. which is from 14 to 30 days. A warning about the drugs delayed therapeutic effect.The nurse is assessing a client who has just been admitted to the emergency department. 17. the physician prescribes tranylcypromine sulfate (Parnate). A warning about the incidence of neuroleptic malignant syndrome (NMS). 3 to 5 days c. Depression and weight loss. and impaired memory d. 16. 6 to 8 days d. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug. The physician prescribed buspirone (BuSpar). To treat her atypical depression. A warning that immediate sedation can occur with a resultant drop in pulse. b. dilated pupils. Combativeness. Classic signs and symptoms of phobias include: a. Demonstrated ability to maintain close. Anticholinergics c. hyperactivity. 20. Severe anxiety and fear. euphoria. d.Which medications have been found to help reduce or eliminate panic attacks? a. Withdrawal and failure to distinguish reality from fantasy. A low tolerance for frustration . Frequent expression of guilt regarding antisocial behavior c. Suggesting new activities for the client and family to do together. 1 to 2 days b. Which of the following traits would the nurse be most likely to uncover during assessment? a. Offering nourishing finger foods to help maintain the client's nutritional status.The nurse is caring for a client diagnosed with antisocial personality disorder. Mood stabilizers 18. Antipsychotics d. and stealing. Antidepressants b. cruelty to animals. c. Emotional lability. 10 mg by mouth twice per day. Which signs would suggest an overdose of an antianxiety agent? a. and confusion b. and grandiose ideation c.A client seeks care because she feels depressed and has gained weight. and increased blood pressure 21. A 65 years old client is in the first stage of Alzheimer's disease. The client has a history of fighting. Monitoring the client to prevent minor illnesses from turning into major problems. The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following? a. 10 to 14 days 19. Suspiciousness.15.

Tim is admitted with a diagnosis of delusions of grandeur. Neologisms 24. Logical thinking c. Avoid shopping for large amounts of food. Which action should the nurse include in the plan? a. Provide privacy during meals. Nurse Marco is developing a plan of care for a client with anorexia nervosa. c. Offering a high-calorie meals and strongly encouraging the client to finish all food. c. b. 27. The plan of care for a client in a manic state would include: a. d. Opiate withdrawal causes severe physical discomfort and can be life-threatening. Restricts visits with the family and friends until the client begins to eat. Insisting that the client remain active through the day so that he¶ll sleep at night. These perceptions are known as: a. Barbiturates b. . Loose associations d. Encourage the client to exercise. d. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Set up a strict eating plan for the client. Control eating impulses. Which coping mechanism is he using? a. Emotional affect d. Hallucinations c. opiate users are commonly detoxified with: a. Highly important or famous. Aggressive behavior b. Independence needs 29. 25. which will reduce her anxiety.22.Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. b.Nurse Amy is providing care for a male client undergoing opiate withdrawal. The most appropriate initial goal for a client diagnosed with bulimia is to: a. manipulative behavior without setting limits. 26. The nurse is aware that this diagnosis reflects a belief that one is: a. Responsible for the evil in the world. Withdrawal b. Connected to events unrelated to oneself d. c.Richard is admitted with a diagnosis of schizotypal personality disorder. b. Identify anxiety-causing situations d.Ramon is admitted for detoxification after a cocaine overdose. To minimize these effects. Being persecuted c. Methadone d. Allowing the client to exhibit hyperactive. demanding. Listening attentively with a neutral attitude and avoiding power struggles. b. Nurse Mickey is caring for a client diagnosed with bulimia. Delusions b. Amphetamines c. Benzodiazepines 23. Repression d. Denial 28. Which signs would this client exhibit during social situations? a. Eat only three meals per day. Paranoid thoughts c.Nurse Jen is caring for a male client with manic depression.

c. the voices are a symptom of your illness. ³It is the voice of your conscience. Adaptation and a return to a prior level of functioning. Bargaining stage d.´ d. Staying in the sun c. the nurse should include cautioning the client against: a. it would be unusual for the nurse to find that this client demonstrated: a. Driving at night b.Jen a nursing student is anxious about the upcoming board examination but is able to study intently and does not become distracted by a roommate¶s talking and loud music. Slow pulse c. Postural hypotension c.´ b.30. Over meticulousness 38. Denial stage 34.The outcome that is unrelated to a crisis state is: a.Nicolas is experiencing hallucinations tells the nurse. Rigidity b. A higher level of anxiety continuing for more than 3 months. c. Severe-level anxiety d.´ 32. don¶t pay any attention to them. Loss of appetite b. which only you can control.When assessing a premorbid personality characteristics of a client with a major depression. Nurse Trish plans to use nonverbal interventions when assessment reveals that the client is in the: a. ³No. Before nay type of treatment is started b. The student¶s ability to ignore distractions and to focus on studying demonstrates: a. ³Oh. but I believe you can hear them´. When developing a teaching plan for discharge.Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. Mild-level anxiety b. The most appropriate response by the nurse would be: a.The nurse is aware that the side effect of electroconvulsive therapy that a client may experience: a. Learning more constructive coping skills b. Basing care on the theory of Kubler-Ross. Anger stage b.Rudolf is admitted for an overdose of amphetamines. As their depression begins to improve c. I do not hear your voices. When their depression is most severe d. Diverse interest d. ³The voices are coming from within you and only you can hear them. When assessing the client. Confusion for a time after treatment d. Tension and irritability b.Nurse Krina recognizes that the suicidal risk for depressed client is greatest: a. Moderate-level anxiety 37. As they lose interest in the environment . Constipation 31. Stubbornness c. Acceptance stage 36. ³The voices are telling me I¶m no good.´ The client asks if the nurse hears the voices. Taking medications containing aspirin c. Decompensation to a lower level of functioning. d. Panic-level anxiety c.A dying male client gradually moves toward resolution of feelings regarding impending death. Complete loss of memory for a time 33. Hypotension d. Ingesting wines and cheeses d. 35. the nurse should expect to see: a.

Presence 43. 40. c. Citrus fruit. Nurse Marian evaluates that learning has occurred when the client states. ³I will call my doctor immediately if I notice any: a. Loss of remote memory related to anoxia b.´ d.Nurse Kate would expect that a client with vascular dementis would experience: a. In the teaching plan for discharge the nurse should include: a. Males are more likely to use lethal methods than are females . Nurse Hazel should explore with the client the: a. and yogurt¶´ c. Client¶s perception of the presenting problem. Reminding the client that a CBC must be done once a month. 4 to 6 months d. aged cheese.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. red meats. Chocolate milk. Suggesting that the client take the pills with milk c. After teaching the client about the medication.i. and carbonated soda. 6 to 12 months 46.Nurse John is a aware that most crisis situations should resolve in about: a. Males account for more attempts than do females c. b. Green leafy vegetables. Client¶s feelings when external. Females use more dramatic methods than males b. ³I will avoid: a. Details of any ritualistic acts carried out by the client d.Josefina is to be discharged on a regimen of lithium carbonate.Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a critical care area is: a. Fine hand tremors or slurred speech c. Empathy d. Loss of abstract thinking related to emotional state c. Nurse Judy knows that statistics show that in adolescent suicide behavior: a. Females talk more about suicide before attempting it d.´ b. Sexual dysfunction or breast enlargement d.´ 45.The psychiatrist orders lithium carbonate 600 mg p. 44. Sensitivity to bright light or sun b. Inability to urinate or difficulty when urinating 42. controls are instituted. and milk. Privacy b.When establishing an initial nurse-client relationship. 4 to 6 weeks c.o t.d for a female client. Nurse Katrina would be aware that the teaching about the side effects of this drug were understood when the client state. tuna. 41. and yellow vegetables. Occurrence of fantasies the client may experience. Advising the client to watch the diet carefully b. d. Inability to concentrate related to decreased stimuli d. 1 to 2 weeks b. Disturbance in recalling recent events related to cerebral hypoxia. Whole grains. chicken.39. Respect c. Encouraging the client to have blood levels checked as ordered.

51.Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Dystonia. "I'm disappointed in you. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately.What herbal medication for depression. These findings suggest which lifethreatening reaction: a. low selfesteem.Nurse Maureen knows that the nonantipsychotic medication used to treat some clients with schizoaffective disorder is: a. Blood pressure must be monitored for hypertension.Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)? a. insomnia. Take time out in your room for 10 minutes. 60 g mixed in 500 ml of water 54." 48. Ginkgo biloba b. the nurse verifies the dosage ordered. Informing the client that this adverse reaction should disappear within 1 week. John's wort d." c. lithium carbonate (Lithane) d. "Your cursing is interrupting the activity. c. Go to your room immediately." b. Neuroleptic malignant syndrome. The client states that these symptoms began at least 2 years ago. b.Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)? a. Dysthymic disorder. poor appetite. Advising the client to sit up for 1 minute before getting out of bed. Atypical affective disorder. 15 g mixed in 500 ml of water c. Mario is admitted to the emergency department. Consulting with the physician about substituting a different type of antidepressant. chlordiazepoxide (Librium) c. poor concentration.Mr. d. c. Ephedra . Monthly blood tests will be necessary. Cruz visits the physician's office to seek treatment for depression. b. d. c. and diaphoresis. widely used in Europe. Based on this report. fever. d. feelings of hopelessness. 5 g mixed in 250 ml of water b. 50. Instructing the client to double the dosage until the problem resolves. fatigue. You can't control yourself even for a few minutes. Cyclothymic disorder. 53. After taking an overdose of phenobarbital (Barbita). Tardive dyskinesia. is now being prescribed in the United States? a. Nursing assessment reveals rigidity. Echinacea c. "Your behavior won't be tolerated. Major depression. 52. Akathisia. Before administering the dose. imipramine (Tofranil) 49.47. Which response by the nurse would be most appropriate? a. "You're just doing this to get back at me for making you come to therapy." d. phenelzine (Nardil) b. the nurse Tyfany suspects: a. Dr. Dervid with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. St. Stop the medication when symptoms subside. Report a sore throat or fever to the physician immediately. b. c. b. hypertension. and difficulty making decisions. What is the usual minimum dose of activated charcoal? a. d. 30 g mixed in 250 ml of water d.

Garcia. b. This medication may be habit forming and will be discontinued as soon as the client feels better. Regression b. It's characterized by a slowly evolving onset and lasts about 1 month. b. d. 59. It's characterized by a slowly evolving onset and lasts about 1 week.Mr. Lack of spontaneity. Which statement about delirium is true? a. Monitor vital signs. pupillary dilation. Severely restrict the client's physical activities. an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism? a. This medication has no serious adverse effects. d.Isabel with a diagnosis of depression is started on imipramine (Tofranil).Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. the nurse should plan to: a. Cocaine withdrawal d. the nurse should observe the client for: a.Edward. b. It's characterized by an acute onset and lasts hours to a number of days. Impaired communication. This medication may initially cause tiredness. c. Calcium b. a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer's type. b. The client should avoid eating such foods as aged cheeses. yogurt. 60. serum electrolyte levels. which should become less bothersome over time. Instruct the client to keep an accurate record of food and fluid intake. 57.Nurse Josefina is caring for a client who has been diagnosed with delirium. 75 mg by mouth at bedtime. Potassium 56. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To promote the client's physical health. The nurse suspects that the client is going through which of the following withdrawals? a.55. It's characterized by an acute onset and lasts about 1 month.Cely with manic episodes is taking lithium. Sodium c. Inability to perform self-care activities. 58. To assess for progression to the middle stage of Alzheimer's disease. c. c. and chicken livers while taking the medication. She complains of nausea and vomiting 24 hours after admission. d. Opioid withdrawal 61. Projection c. Alcohol withdrawal b. d. and acid-base balance. The nurse assesses the client and notes piloerection. Reaction-formation d. and lacrimation. The nurse should tell the client that: a. Intellectualization . Which electrolyte level should the nurse check before administering this medication? a. Weigh the client daily. after the evening meal. Occasional irritable outbursts. Chloride d. c.Celia with a history of polysubstance abuse is admitted to the facility. Cannibis withdrawal c.

Slurred speech b. Heroin b. Sensory perceptual change . The client verbalizes the reasons for the violent behavior. Severe 67. Engage in diversionary activities when acting -out b. Cocaine c. Severe headache. d.Jeremy is brought to the emergency room by friends who state that he took something an hour ago.´ c. Profound b. Blurred vision d. He is actively hallucinating. Abnormal movements and involuntary movements of the mouth. If tardive dyskinesia is present.Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. tremors. a 9 year old child has very limited vocabulary and interaction skills. Nurse Anne checks the client for tardive dyskinesia. c. a. Nurse Anne would most likely observe: a. Abnormal breathing through the nostrils accompanied by a ³thrill. Nurse determines that it will be safe to remove the restraints when: a. flushing. The administered medication has taken effect. Fecal incontinence 64.Dennis has a lithium level of 2. Provide safety measures d. d. b. LSD d.4 mEq/L.The therapeutic approach in the care of Armand an autistic child include the following EXCEPT: a.Nurse Jannah is monitoring a male client who has been placed inrestraints because of violent behavior. Diarrhea c.Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. migraine headache. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Bradycardia and diarrhea 66. b. Increased attention span and concentration b. Marijuana 69.Nurse Pauline is aware that Dementia unlike delirium is characterized by: a. 65. with irritated nasal septum. The nurse immediately would assess the client for which of the following signs or symptoms? a. and ataxia.62. Rearrange the environment to activate the child 68. Provide an atmosphere of acceptance c. The client apologizes and tells the nurse that it will never happen again. During the assessment. The side effects of the following may be noted by the nurse: a. Insidious onset c. agitated. Moderate d. Severe hypertension. and face.Q. She has an I.Kitty. tongue. She is diagnosed to have Mental retardation of this classification: a. Clouding of consciousness d. 63. Weakness b. Sleepiness and lethargy d. of 45. Mild c. Increase in appetite c.

Revealing personal information to the client b. Hypertension 77. A therapy that rewards adaptive behavior b. Conversion disorder b. Confronting the client about discrepancies in verbal or non-verbal behavior d. without apparent reason.Anthony is very hostile toward one of the staff for no apparent reason. Adventitious c. Give the client Cogentin c. a newly admitted is extremely hostile toward a staff member she has just met. Transference c.A 35 year old female has intense fear of riding an elevator. Obesity b.Katrina. What should the nurse in-charge do first: a. A cognitive approach to change behavior c. Severe anxiety d. Developmental d. These symptoms indicate which of the following disorders? a. learning or working environment. Hold the next dose and obtain an order for a stat serum lithium level 73. the nurse should suspect that the client is experiencing which of the following phenomena? a. A permissive and congenial environment 74. Sublimation . Claustrophobia d. Situational b. 72. Splitting 78. Agoraphobia b. She is brought to the hospital by her mother. He is manifesting: a. According to Freudian theory. Hypochondriasis c. Internal 76. Countertransference d. d.Nurse Myrna develops a counter-transference reaction. Which of the following best describes a therapeutic milieu? a. Focusing on the feelings of the client.70. c. Social phobia c. Rape is an example of which type of crisis: a.An 83year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. The client feels angry towards the nurse who resembles his mother. 17 years old was sexually attacked while on her way home from school. Resistance 75. Xenophobia 71. Borderline personality disorder c. Intellectualization b. She claims ³ As if I will die inside. A living. Splitting b. Triangulation d.Marielle. Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders. This is evidenced by: a. Recognize this as a drug interaction b.Tristan is on Lithium has suffered from diarrhea and vomiting. Transference c. Text Revision (DSM-IV-TR) is: a.´ The client is suffering from: a. Major depression d. Reassure the client that these are common side effects of lithium therapy d.Nurse Sarah ensures a therapeutic environment for all the client.

Stopping the drug increases cognitive abilities c. ³I¶ve lost my craving for alcohol´ d. These symptoms are typically of which of the following disorders? a. I¶ve lost my phobia for water´ 84. Stopping the drug may cause depression b. Which of the following statements indicates a positive client response? a. Jennifer. It promotes emotional support or attention for the client 82. Conversion disorder b. ³Last night I decided to eat more than a bowl of cereal´ 83. Labile moods . Stopping the drug can cause withdrawal symptoms 85. ³I¶m sleeping better and don¶t have nightmares´ b. It brings some stability to the family b. It decreases the preoccupation with the physical illness c. Mark. ³I¶m hyperventilating only when I have a panic attack´ c. Aldo. ³I went to the mall with my friends last Saturday´ b. Although physical causes have been eliminated. an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Charina. Which of the following statement refers to a secondary gain? a. Dervid is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Anxiety disorder b. Behavioral difficulties c. Cognitive impairment d. Paroxetine (Paxil)\ c. Triazolam (Halcion) b. the student continues to express her belief that she has a serious illness. Nurse Daisy is aware that the following pharmacologic agents are sedativehypnotic medication is used to induce sleep for a client experiencing a sleep disorder is: a.79. Fluoxetine (Prozac) d. Stopping the drug decreases sleeping difficulties d. It enables the client to avoid some unpleasant activity d. Hypochondriasis d. with a somatoform pain disorder may obtain secondary gain. Risperidone (Risperdal) 81. Somatization disorder 80. Depersonalization c. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder can be demonstrated by which of the following client self ±reports? a. Which of the following other health problems would the nurse suspect? a. with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). ³I¶m not losing my temper as much´ c. a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication? a. ³Today I decided that I can stop taking my medication´ d.

The inability to perform motor activities occurs in vascular dementia 88. Ideas of reference d. Explain effects of serotonin syndrome b. The client becomes anxious whenever the nurse leaves the bedside d. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. Which of the following terms describes this disorder? a. When the nurse asks questions. Vascular dementia has more abrupt onset b. Teach the client to watch for extrapyramidal adverse reaction c. The client is experiencing visual hallucination 90. an outpatient in psychiatric facility is diagnosed with dysthymic disorder. ³They¶re crawling on my sheets! Get them off my bed!´ Which of the following assessment is the most accurate? a. The duration of vascular dementia is usually brief c. Antisocial b. The nurse is aware that the following ways in vascular dementia different from Alzheimer¶s disease is: a. Discuss the need to report paradoxical effects such as euphoria .and diazepam (Valium) for anxiety. It involves a single manic depression c. Flight of ideas b. The client says. Paranoid d. Loretta. Concrete thinking c. She had been taking digoxin. Francis tells the nurse that her coworkers are sabotaging the computer. Metabolic acidosis c. Hepatic encephalopathy 89.86. The client is experiencing aphasia b. a newly admitted client was diagnosed with delirium and has histo ry of hypertension and anxiety. furosemide (Lasix). Which of the following descriptions of a client¶s experience and behavior can be assessed as an illusion? a. The client is experiencing a flight of ideas d. Schizotypal 93. the client becomes argumentative. ³I keep hearing a voice telling me to run away´ c. Histrionic c. It involves a mood range from moderate depression to hypomania b. Explain that the drug is less affective if the client smokes d. It¶s a form of depression that occurs in the fall and winter d. Nurse Ron enters a client¶s room. During conversation of Nurse John with a client. It¶s a mood disorder similar to major depression but of mild to moderate severity 87. Personality change is common in vascular dementia d. This behavior shows personality traits associated with which of the following personality disorder? a. Ricardo. 91. Loose association 92. This client¶s impairment may be related to which of the following conditions? a. Drug intoxication d. The client tries to hit the nurse when vital signs must be taken b. he observes that the client shift from one topic to the next on a regular basis. The client is experiencing dysarthria c. Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine (Zyprexa)? a. Infection b. Which of the following statement about dysthymic disorder is true? a. the client says.

Belief in superstition c. ³I thought the nurse was my mirror. Idea of reference 99. Disorganized speech c. Lack of honesty b. Show of temper tantrums d. Refer him for anticholinergic adverse reactions c. During recovery. Rationalization c. Ritualism 98. She scratches while she tells the nurse she feels creatures eating away at her skin. Ivy. Which of the following terms describes the client¶s perception? a. Which of the following defense mechanisms is probably used by mike? a. Which of the following statements by the Tommy shows teaching was successful? a. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Projection b. Delusion b.94. Assess for possible physical problems such as rash d. ³I¶m not going to look just at the negative things about myself´ b. Constant need for attention 95. Regression d. Norma. ³I¶m not as envious of the things other people have as I used to be´ d. ³I¶m most concerned about my level of competence and progress´ c. Should report feelings of restlessness or agitation at once b. ³I find I can¶t stop myself from taking over things other should be doing´ 96. with dependent personality disorder is working to increase his self esteem. Modeling b. a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. Use a sunscreen outdoors on a year-round basis c. Ego-syntonicity d. Talk about his hallucinations and fears b. I felt connected only when I saw my nurse. who is on the psychiatric unit is copying and imitating the movements of her primary nurse. Which of the following interventions should be done first? a. Call his physician to get his medication increased to control his psychosis 97. When discussing appropriate behavior in group therapy. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder.´ This behavior is known by which of the following terms? a. Echopraxia c. Hallucination d. This drug will indirectly control essential hypertension . Be aware you¶ll feel increased energy taking this drug d. Tommy. Which of the following instructions is most appropriate for Ricky before taking haloperidol? a. Rocky has started taking haloperidol (Haldol). she says. Jun approaches the nurse and tells that he hears a voice telling him that he¶s evil and deserves to die. which of the following comments is expected about this client by his peers? a. Repression 100.

Answer: (B) Standard written order Rationale: This is a standard written order. A standing order. route because the area is a highly vascular and can bleed readily when penetrated by a needle. Answer: (A) Prevent stress ulcer Rationale: Curling¶s ulcer occurs as a generalized stress response in burn patients. once daily´ Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure. and hyponatremia. which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the client¶s circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. Rationale: Restraints encircle the limbs. no nursing action is warranted. coordinated and comprehensive nursing services. The bleeding can be difficult to stop. Beyond continued evaluation. Answer: (D) Continue to monitor and record hourly urine output Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). brown. possibly leading to a tenfold increase in the dosage. Answer: (D) The actions of a reasonably prudent nurse with similar education and experience. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion. Therefore. 12. Rationale: Ice application decreases pain and swelling. 5. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. Prescribers write a single order for medications given only once.TEST I Answers and Rationale ± Foundation of Professional Nursing Practice 1. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult. along with it.M Rationale: With a platelet count of 22. and diligence by nurses in similar circumstances. Clients with fecal impaction don't pass hard. . 6. 2.000/ l.125 mg P. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients.M. Answer: (C) Check circulation every 15-30 minutes. establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. and increased warmth are signs of inflammation that shouldn't occur after ice application 10. 4. 15. the clients tends to bleed easily. This results in a decreased production of mucus and increased secretion of gastric acid. Continued or increased pain. The best treatment for this prophylactic use of antacids and H2 receptor blockers. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided.O. which could result in a dosage error. this client's output is normal. 11. Rationale: The standard of care is determined by the average degree of skill. Answer: (C) ³Digoxin 0. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. 7. A stat order is written for medications given immediately for an urgent client problem. hypovolemia. 14. redness. 3. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. sodium and potassium. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and. This may result in hypokalemia. For a child. care. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Answer: (B) I. 8. Therefore. formed stools because the feces can't move past the impaction. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. Answer: (A) Provides continuous. the nurse should avoid using the I. Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. Answer: (B) ³My ankle feels warm´. 13. 9. the nurse grasps the helix and pulls it down to straighten the ear canal. also known as a protocol.

The Trendelenburg position increases intrathoracic pressure. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation. 20. Answer: (B) Assess the client for presence of pain. Caloric goals may be as high as 5000 calories per day. The client is at high risk for infection because of the decreased body defenses against microorganisms. Rationale: Assessing the client for pain is a very important measure. clammy skin. and it includes the basic ideas which are found in the other options 31. Answer: (A) Blood pressure and pulse rate. and comparing the patient¶s behavioral responses with the expected outcomes. 21. and combs must be removed. cold. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. and record the appropriate information in the client¶s chart.5 cc Rationale: 2. Answer: (A) Take the proper equipment. Answer: (A) Protect the irritated skin from sunlight. 33. Rationale: A positive nitrogen balance is important for meeting metabolic needs. splinting the area before moving the client is imperative. This reduces the exposure of others to the radiation. Answer: (A) Autocratic. 29.16. Answer: (D) Sudden onset of continuous epigastric and back pain. Answer: (B) Evaluation Rationale: Evaluation includes observing the person. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. and possible hemorrhage. Rationale: The autocratic style of leadership is a task-oriented and directive. Rationale: Dentures. properly placed. Answer: (B) Admit the client into a private room.5 cc is to be added. 28. . 25. tissue repair. Answer: (D) 2. provides resistance to the external rotation of the hip. 26. 19. Rationale: It is a general or comprehensive statement about the correct procedure. The priority approach is the avoidance of strong sunlight. Continuous. Rationale: If the nurse suspects a fracture. Pulse ± 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure. Rationale: A trochanter roll. 18. 24. 23. Answer: (C) Assist the client in removing dentures and nail polish. place the client in a comfortable position. because only a 500 cc bag of solution is being medicated instead of a 1 liter. 17. unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. 22. The nurse should also assess the client for pain to provide for the client¶s comfort. rapid and weak irregular pulse. 27. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. 32. and resistance to infection. hairpins. decreased urinary output. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. Postoperative pain is an indication of complication. high-carbohydrate diet. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. Answer: (A) BP ± 80/60. 30. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion. asking questions. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. Answer: (B) Provide high-protein. edema. Answer: (B) Place the client on the left side in the Trendelenburg position. which decreases the amount of blood pulled into the vena cava during aspiration. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. Answer: (C) History of present illness Rationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person¶s needs. Answer: (D) Immobilize the leg before moving the client. and cerebral hypoxia.

it must be replaced). Answer: (A) 0.75 Rationale: To determine the number of milliliters the client should receive. Names on bed aren¶t always reliable 43. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. not a standard measure of weight or quantity. especially close vision. If a clamp isn¶t available. the nurse uses the fraction method in the following equation. Answer: (B) 32 drops/minute Rationale: Giving 1. Answer: (A) Second intention healing Rationale: When wounds dehisce. 35. After cleaning the hub with alcohol or povidone-iodine solution.V. Checking all connections and taping them will prevent air leaks. 75 mg/X ml = 100 mg/1 ml To solve for X. Percussion and palpation can alter natural findings during auscultation. Rationale: Failing eyesight. the nurse can place a sterile syringe or catheter plug in the catheter hub. they will allowed to heal by secondary intention 36. causing an increase in heart rate. and palpation.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute. Different drugs measured in units may have no relationship to one another in quality or quantity.9 °C Rationale: To convert Fahrenheit degreed to Centigrade. Increase in loss of muscle tone occurs in later years (age 80 and older). Answer: (C) Failing eyesight. the nurse must replace the I. a deep crater or without undermining of adjacent tissue is noted. not a standard measure of weight or quantity. Answer: (B) 38.34. Answer: (D) Auscultation. Answer: (A) Check the client¶s identification band. Asking the client¶s name or having the client repeated his name would be appropriate only for a client who¶s alert. oriented. Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit. is one of the first signs of aging in middle life (ages 46 to 64). ml) = X 38. and palpation. compensatory mechanisms stimulate the heart. Rationale: Checking the client¶s identification band is the safest way to verify a client¶s identity because the band is assigned on admission and isn¶t be removed at any time. Answer: (C) Stage III Rationale: Clinically. The chest drainage system is kept lower to promote drainage not to prevent leaks. 37. Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected.75 ml (or . (If it is removed.9 40. extension and restart the infusion. Rationale: An insulin unit is a measure of effect. Rationale: The correct order of assessment for examining the abdomen is inspection. especially close vision. the nurse should immediately apply a catheter clamp. percussion.8 °C = (102 ± 32) ÷ 1.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes).8 °C = 38. 42. or 32 drops/minute 44. percussion. cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0. 45. 39. and able to understand what is being said. use this formula °C = (°F ± 32) ÷ 1. if available. Answer: (D) It¶s a measure of effect. Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.8 °C = 70 ÷ 1. auscultation. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isn¶t secure. . but isn¶t the safe standard of practice. More frequent aches and pains begin in the early late years (ages 65 to 79). 41.

Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. or retrospective. When a client is in ventricular tachycardia. and vocal vibrations through the chest wall. This method promotes venous return. such as family history. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value. The client is instructed to look up and outward rather than at his or her feet. more frequent examinations may be necessary. 54. or ball. Beginning at the ankle. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. 47. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurse¶s realm of interventions and will protect the area. Answer: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. Answer: (B) On the affected side of the client.32 is acidotic. A urine output of 45 ml per hour indicates adequate renal perfusion. Rationale: A urine specimen is not taken from the urinary drainage bag. Rationale: Hospices provide supportive care for terminally ill clients and their families. Answer: (D ) Obtaining the specimen from the urinary drainage bag. . Answer: (B) To provide support for the client and family in coping with terminal illness. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. Massaging with an astringent can further damage the skin. A serum pH of 7. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface. which adversely affects all body tissues. 57. genetic tendency. the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. 56. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells. the pH and bicarbonate (Hco3) values are below normal. The dorsal surface best feels warmth. 53. 51. In this case. Rationale: When walking with clients. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. or knee does not promote venous return. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. the nurse should begin applying the bandage at the client¶s foot. Hospice care doesn¶t focus on counseling regarding health care costs. However. Summative. Informative is not a type of evaluation. of the hand to asses tactile fremitus. it may become contaminated with bacteria from opening the system. checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. Answer: (D) Check the client¶s level of consciousness Rationale: Determining unresponsiveness is the first step assessment action to take. evaluation occurs at the conclusion of the teaching and learning session. In metabolic alkalosis. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. 49. However. 58. or past breast cancer. In metabolic acidosis. lower thigh. thrills. the pH value is above normal and in the Paco2 value is below normal. If health risks. the pH and Hco3 values are above normal. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. 52. causing hypokalemia.46. exist. 48. In respiratory alkalosis. indicating respiratory acidosis. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. Using a povidone-iodine wash and an antibiotic cream require a physician¶s order. there is a significant decrease in cardiac output. 50. The fingertips and finger pads best distinguish texture and shape. In addition. the client usually develops tolerance 55.

therefore. hence laboratory data is essential. If the client is unable to sit up. Answer: (B) Cover the client. secretions. Answer: (A) Puts all the four points of the walker flat on the floor. Answer: (C) Use a sterile plastic container for obtaining the specimen. Additionally. is not one of the options. However. To maintain privacy and safety.correlational Rationale: Descriptive. 62. Rationale: When the client uses a walker. Shoe protectors are not necessary. An error is never erased and correction fluid is never used in the medical record. the nurse covers the client and places the call light within the client¶s reach.59. particularly in vitro measurements. the client should not move self. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. Answer: (A) Descriptive. Rationale: To facilitate removal of fluid from the chest wall. the nurse draws one line through the incorrect information and then initials the error. 72. the nurse stands adjacent to the affected side. 64.correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures. Rationale: Because telephone call is an emergency. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. A cane is better suited for client with weakness of the arm and leg on one side. 60. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. place the call light within reach. . However. Answer: (C) Secures the client safety belts after transferring to the stretcher. If the procedure for obtaining the specimen is not sterile. body fluids. then the specimen would be contaminated and the results of the test would be invalid. then the specimen is not sterile. puts weight on the hand pieces. 70. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. Rationale: During the transfer of the client after the surgical procedure is complete. Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. 61. the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. In contrast to this is a secondary source. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Rationale: To correct an error documented in a medical record. the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. or excretions may occur. 69. 66. Goggles are not necessary unless the nurse anticipates the splashes of blood. 68. At the time of the transfer from the surgery table to the stretcher. 65. and then walks into it. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. This will ensure client safety and prevent stress cracks in the walker. which is written by someone other than the original researcher. the client is still affected by the effects of the anesthesia. Answer: (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. The client is then instructed to move the walker forward and walk into it. Safety belts can prevent the client from falling off the stretcher. The other appropriate action is to ask another nurse to accept the call. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. 63. and answer the phone call. 71. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. the nurse should avoid exposure of the client because of the risk for potential heat loss. the nurse may need to answer it. the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. 67. the client¶s door should be closed or the room curtains pulled around the bathing area.

Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. If the client can't assume this . Canvas shoes cause the feet to perspire. self-concept mode. making it less helpful in tissue repair. Answer: (A) Span of control Rationale: Span of control refers to the number of workers who report directly to a manager.73. including the risks involved and the alternative solutions. 88. 84. subpoena or subpoena duces tecum as needed. 76. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. Answer: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture. 87. Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. 74. This means in operational terms that the injury caused is the proof that there was a negligent act. Both cotton and cornstarch absorb perspiration. a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed. which may. 79. cause skin irritation and breakdown. They performed differently because they were under observation. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. 78. Callista Roy developed the Adaptation Model which involves the physiologic mode. b) at least four years has elapsed since the license has been revoked. in turn. Ice cream supplies only some incomplete protein. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to avoid wearing canvas shoes. Answer: (A) Degree of agreement and disagreement Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study 83. the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. 82. Answer: (B) The Board can investigate violations of the nursing law and code of ethics Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons. Oranges and broccoli supply vitamin C but not protein. 77. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. role function mode and dependence mode. 85. Answer: (D) Sims¶ left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. 81. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem. Answer: (B) Sr. 80. To do good is referred as beneficence. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. and. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. The client should be instructed to cut toenails straight across with nail clippers. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. which this client needs to repair the tissue breakdown caused by pressure ulcers. Callista Roy Rationale: Sr. In giving consent it is done with full knowledge and is given freely. 86. 75. 24 states that for equity and justice.

Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. and dyspnea. Also. Answer:(A) Instructing the client to report any itching. Answer: (A) The nurse can implement medication orders quickly. 94. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Implementation is the phase of the nursing process where the nurse puts the plan of care into action. When the stockings are in place. the dorsal recumbent or right lateral position may be used. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention. swelling. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes. according to facility policy. The supine and prone positions are inappropriate and uncomfortable for the client. Signs and symptoms of life-threatening allergic reactions include itching. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions. For measurement of the trough. Feedings are normally given at room temperature to minimize abdominal cramping. Answer: (B) Immediately before administering the next dose. The nurse should apply the face mask from the client's nose down to the chin ² not vice versa. altering its action. 91. 97. Answer: (A) Arrange for typing and cross matching of the client¶s blood. and the veins can fill with blood. loosened connectors can cause loss of oxygen. Although the nurse should inform the client of the duration of the transfusion and should document its administration. which helps dissolve the medication. the nurse draws a blood sample immediately before administering the next dose. Rationale: Rolling the vial gently between the palms produces heat. Discard or return to the blood bank any blood not given within this time. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. The other options are normal abdominal findings. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. the leg muscles can still stretch and relax. Answer: (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. . an abnormal finding. Depending on the drug's duration of action and half-life. whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. and oxygen intake. 93. the nurse promotes easier chest expansion. although appropriate when preparing to administer a blood transfusion. To prevent aspiration during feeding. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. Administering an already-prescribed drug on time is a dependent intervention. or dyspnea. which could lead to irritation. 100. peak blood drug levels typically are drawn after administering the next dose. or lowest. or dependent. and laboratory studies. Doing nothing or inverting the vial wouldn't help dissolve the medication. An intradependent nursing intervention doesn't exist. Shaking the vial vigorously could cause the medication to break down. Rationale: A floor stock system enables the nurse to implement medication orders quickly. Answer: (B) Assist the client to the semi-Fowler position if possible. interdependent. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. physical examination. Answer: (D) Roll the vial gently between the palms. the head of the client's bed should be elevated at least 30 degrees. Answer: (B) Decrease the rate of feedings and the concentration of the formula. 96. come later. nor does it minimize transcription errors or reinforce accurate calculations. Assessment consists of the client's history. 99. 98. these actions are less critical to the client's immediate health. It doesn't allow for pharmacist input. blood level of a drug. breathing. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight. 89.position nor has poor sphincter control. Rationale: Shifting dullness over the abdomen indicates ascites. swelling. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly. The nurse should assess vital signs at least hourly during the transfusion. Applying the stockings increases blood flow to the heart. 92. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. feeding containers should be routinely changed every 8 to 12 hours. the nurse must monitor the client for these effects. The findings show that the expected outcomes have been achieved. 95. Answer: (C) Shifting dullness over the abdomen. Answer: (A) Independent Rationale: Nursing interventions are classified as independent. to prevent bacterial growth. Rationale: By assisting the client to the semi-Fowler position. The other options. 90.

12. Because they could damage the operative site. Fetal activity would not be noted. which could interfere with healing and damage the cosmetic appearance of the repair. At age 4 to 6 months. minutes lasting 70-80 seconds. failure to detect fetal heart activity even with sensitive instruments. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin. 11. Answer: (D) First low transverse caesarean was for breech position. An elevated pulse rate is an indicator of shock. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. Rationale: Contractions every 1 . infants can¶t sit securely alone. Fetus in this pregnancy is in a vertex presentation. the best approach is to talk to the mother and ignore the toddler first. larger than normal uterus for gestational age. Answer: (A) Excessive fetal activity. 3. suction catheters. but insulin does not. 4. combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. 14. Answer: (A) Contractions every 1 . Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis. infants can sit securely alone but cannot understand the permanence of objects. Answer: (C) Iron-rich formula only. such as objects as pacifiers. and small spoons shouldn¶t be placed in a baby¶s mouth after cleft repair. This increases the mother¶s demand for insulin and is referred to as the diabetogenic effect of pregnancy. and early development of pregnancyinduced hypertension.TEST II Answers and Rationale ± Community Health Nursing and Care of the Mother and Child 1. Answer: (A) Talk to the mother first and then to the toddler. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia. High fetal demands for glucose. 6. This approach helps the toddler get used to the nurse before she attempts any procedures. A baby in a prone position may rub her face on the sheets and traumatize the operative site. 7. Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. which could result in injury to the mother and the fetus if Pitocin is not discontinued. Answer: (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. 9. It also gives the toddler an opportunity to see that the mother trusts the nurse. Answer: (B) Allow the infant to rest before feeding. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. . The suture line should be cleaned gently to prevent infection. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. an infant with heart failure should rest before feeding. Rationale: When dealing with a crying toddler. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Rationale: Because feeding requires so much energy. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. 2. 15. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn¶t receive solid food. At age 8 months. minutes lasting 70-80 seconds. so he would look for the hidden toy. is indicative of hyperstimulation of the uterus. 8. 5. which requires administration of calcium gluconate. Answer: (D) Place the infant¶s arms in soft elbow restraints. excessive nausea and vomiting. 13. and rubella are causes of spontaneous abortion. 10. toxoplasmosis. vaginal bleeding. Answer: (B) Increased caloric intake Rationale: Glucose crosses the placenta. even baby food until age 6 months.

and premature rupture of the membranes aren't associated with DIC. Answer: (D) Rural Health Unit Rationale: R. 29. prevention of permanent disability and disability limitation appropriate for convalescents.000. Answer: (B) Measles Rationale: Presidential Proclamation No. complicated cases and the terminally ill (those in the terminal stage of a disease). Answer: (C) Blood typing Rationale: Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. or polysplenia. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. services. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation. if clotting factors are depleted. the disabled.V. Approximately 40% of a woman¶s cardiac output is delivered to the uterus. therefore. B and C are objectives of contributory objectives to this goal. because of the risk of epiglottitis. 25. DIC may occur. sitting up in his mother¶s arms and drooling. 35. Answer: (A) 1 Rationale: Each rural health midwife is given a population assignment of about 5. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. Answer: (D) Public health nursing focuses on preventive. blood loss can occur quite rapidly in the event of uncontrolled bleeding.A. . Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system. 22. 32. Answer: (A) Change the diaper more often. Rationale: Intrauterine fetal death. Rationale: The catchments area in PHN consists of a residential community. 27. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. 24. the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. Answer: (D) Endocardial cushion defect Rationale: Endocardial cushion defects are seen most in children with Down syndrome. Answer: (D) To maximize the community¶s resources in dealing with health problems. Answer: (A) Intrauterine fetal death. 30. 23. septic shock. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I. Answer: (B) Efficiency Rationale: Efficiency is determining whether the goals were attained at the least possible cost. asplenia. 7160 devolved basic health services to local government units (LGU¶s ). Rationale: The infant with the airway emergency should be treated first. 20. not curative. 33. The public health nurse is an employee of the LGU. A.16. many of whom are well individuals who have greater need for preventive rather than curative services. Answer: (B) Health education and community organizing are necessary in providing community health services. dysfunctional labor. Placenta accreta. Rationale: Community organizing is a developmental service. 17. 19. Answer: (A) Mayor Rationale: The local executive serves as the chairman of the Municipal Health Board. 21. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. 28. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour. Answer: (D) Core group formation Rationale: In core group formation. with the goal of developing the people¶s self-reliance in dealing with community health problems. and amniotic fluid embolism may trigger normal clotting mechanisms. 31. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. because magnesium is excreted through the kidneys and can easily accumulate to toxic levels. 26. 34. Answer: (D) A 2 year old infant with stridorous breath sounds. 18. abruptio placentae. 4 is on the Ligtas Tigdas Program.

Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS. Rationale: A loud. machinery-like murmur. Answer: (A) The older one gets. Rationale: Rubella vaccine is made up of attenuated German measles viruses. Streptococcus pneumonia and Neisseria meningitidis may cause meningitis. therefore. 37. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test. as well as seizure disorders. 51. 38.V. such as pallor or cyanosis. 40. Answer: (A) Loud. restlessness is the earliest sign of hypoxia. In developing countries. Answer: (B) Walk one step ahead. 47. the nurse should withhold the potassium and notify the physician. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections. 46. 39. 44. a specific prophylactic against German measles. because the female worm lays eggs at night around the perineal area. 48. are higher in incidence in adults. the first bowel movement of the day will yield the best results. 45. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. like rats. Answer: (D) Leptospirosis Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals. If the client is not voiding. Late signs of hypoxia in a child are associated with a change in color. This condition results in irritability and changes in level of consciousness. 52. Answer: (C) More oxygen. the infant requires more oxygen and there is an increase in metabolic rate. with the child¶s hand on the nurse¶s elbow. hormonal variations do occur and can result in early or late ovulation.36. Answer: (D) Consult a physician who may give them rubella immunoglobulin. and learning disabilities. Answer: (D) Early in the morning Rationale: Based on the nurse¶s knowledge of microbiology. This is contraindicated in pregnancy. Rationale: When cold. Rationale: This procedure is generally recommended to follow in guiding a person who is blind. Answer: (D) ³I really need to use the diaphragm and jelly most during the middle of my menstrual cycle´. machinery-like murmur is a characteristic finding associated with patent ductus arteriosus. the diaphragm should be inserted before every intercourse. the newborn increase heat production. steatorrhea. Immune globulin. therefore. the peak incidence is in children less than 6 months of age. to any client. Morbillivirus is the etiology of measles. Answer: (D) Voided Rationale: Before administering potassium I. 42. 43. Answer: (B) Buccal mucosa Rationale: Koplik¶s spot may be seen on the mucosa of the mouth or the throat. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Rationale: Chicken pox is usually more severe in adults than in children. To be effective. such as sexually transmitted diseases. Complications. but the flow will be slow enough not to overload the stomach too rapidly. Giardiasis is characterized by fat malabsorption and. Rationale: The woman must understand that. although the ³fertile´ period is approximately mid-cycle. and the newborn¶s metabolic rate increases. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption. the specimen should be collected early in the morning. but age distribution is not specific in young children. such as pneumonia. the more susceptible he becomes to the complications of chicken pox. may be given to pregnant women. The rationale for this timing is that. 50. hyperactivity. the nurse must first check that the client¶s kidneys are functioning and that the client is voiding. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity. 49. causing increased intracranial pressure. . Answer: (C) Restlessness Rationale: In a child. 41. The topical allergen that is the most common causative factor is laundry detergent.

referral to a facility where IV fluids can be initiated within 30 minutes.53. The lungs are the most immature system during the gestation period. the first question to determine malaria risk is where the client¶s family resides. then urgent referral to the hospital is done. 65. The appropriate storage temperature of DPT is 2 to 8° C only. 61. Answer: (C) Normal Rationale: In IMCI. 69. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI. The mother will have active artificial immunity lasting for about 10 years. 54. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. 63. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy. Answer: (A) 45 infants Rationale: To estimate the number of infants. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. This is why BCG immunization is scheduled only in the morning. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. vomits everything. he has to be referred urgently to a hospital. Answer: (A) Refer the child urgently to a hospital for confinement. Rationale: If the child vomits persistently. 59. Answer: (A) 1 year Rationale: The baby will have passive natural immunity by placental transfer of antibodies. convulsions. 66. that is. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks¶ gestation. 68. Otherwise. 56. MMR is not an immunization in the Expanded Program on Immunization. a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable. Medical care for premature labor begins much earlier (aggressively at 21 weeks¶ gestation) . 64. Answer: (A) Inability to drink Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink. 67. sunken eyes. 5 doses will give the mother lifetime protection. abnormally sleepy or difficult to awaken. The best management is urgent referral to a hospital. positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. ask if the child had traveled within the past 6 months. Answer: (B) 6 months Rationale: After 6 months. 60. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. he vomits everything that he takes in. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day. OPV and measles vaccine are highly sensitive to heat and require freezing. only BCG is discarded 4 hours after reconstitution. 58. where she was brought and whether she stayed overnight in that area. Oresol or nasogastric tube. If the area of residence is not a known endemic area. Answer: (A) DPT Rationale: DPT is sensitive to freezing. vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation. 57. Rationale: ³Baggy pants´ is a sign of severe marasmus. multiply total population by 3%. the lungs are developed enough to sometimes maintain extrauterine life. Answer: (B) Ask where the family resides. can no longer be provided by mother¶s milk alone. Rationale: Because malaria is endemic. 55. Teach the mother to give Oresol more slowly. the baby¶s nutrient needs. 62. especially the baby¶s iron requirement. When the foregoing measures are not possible or effective. sweating and hair growth over the lesion. Answer: (D) 5 skin lesions. the skin goes back slow after a skin pinch.

and indicating a desire to see the newborn are behaviors indicating parental bonding. Answer: (C) ³What is your expected due date?´ Rationale: When obtaining the history of a client who may be in labor. These neonates are usually very alert. After the airway is clear and the neonate's color improves. Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. Administering oxygen when the airway isn't clear would be ineffective. 71. and the epidermis may become desquamated. the nurse should notify the physician. respiratory rate more than 60 breaths/minute. Answer: (B) Instructing the client to use two or more peripads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. . Fetal position is determined by vaginal examination. Infants aren¶t given tub bath but are sponged off until the cord falls off. Peroxide could be painful and isn¶t recommended. Petroleum jelly prevents the cord from drying and encourages infection. the nurse should ask about chronic illnesses. 82. Observing for pooling of straw-colored fluid. Artificial rupture of membranes doesn't indicate an imminent delivery. particularly her due date. Answer: (D) Aspirate the neonate¶s nose and mouth with a bulb syringe. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy. Bulging fontanelles are a sign of intracranial pressure. 78. and bradycardia. The serum blood sugar isn¶t affected by magnesium sulfate. Lanugo is missing in the postdate neonate. and audible grunting are signs of respiratory distress. If the problem recurs or the neonate's color doesn't improve readily. the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. Suffocation would be less likely with an infant supine than prone and the position for GER requires the head of the bed to be elevated. Simian creases are present in 40% of the neonates with trisomy 21. Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. checking vaginal discharge with nitrazine paper. Later. Answer: (D) The parents¶ interactions with each other. 79. gravidity. especially when it results in a low temperature in the neonate. the nurse should comfort and calm the neonate. Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. 73. expressing interest about the newborn's size. sitz baths. 83. The neonate with an infection will usually show a decrease in activity level or lethargy. 76. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. The most effective way to do this is to check the fetal heart rate. 75. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. and parity. the nurse's highest priority is to determine her current status. The neonate would be floppy. The neonate¶s color often changes with an infection process but generally becomes ashen or mottled. Fetal well-being is assessed via a nonstress test. Answer: (C) Respiratory rate 40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional period. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Nasal flaring. Gravidity and parity affect the duration of labor and the potential for labor complications. Answer: (C) Decreased temperature Rationale: Temperature instability. The risk of aspiration is slightly increased with the supine position. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression. Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Cold applications. allergies. 74. 80. may be a sign of infection. and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. and Kegel exercises are important measures when the client has a fourth-degree laceration. 77. not jittery. hypotonia. Cystic hygroma is a neck mass that can affect the airway. and support persons. 72. 81. Willingness to touch and hold the newborn. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.70. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa.

91. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. External fetal monitoring won¶t detect a placenta previa. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. although it will detect fetal distress. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. 94. Long-acting insulin usually isn¶t needed for blood glucose control in the client with gestational diabetes. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Because cooling increases the risk of acidosis. Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. 90. The placenta can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks. 93. The inspiratory capacity increases during pregnancy. which may result from blood loss or placenta separation. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. 86. 87. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins.V. Cleavage in conjoined twins occurs more than 13 days after fertilization. 88. Antihypertensive drugs usually aren¶t necessary. Oral hypoglycemic drugs are contraindicated in pregnancy. then twins don¶t¶ gain weight as rapidly as singletons of the same gestational age. Answer: (D) Ultrasound Rationale: Once the mother and the fetus are stabilized. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. Antihypertensive drug other than magnesium are preferred for sustained hypertension. Diuretic wouldn¶t be used unless fluid overload resulted. push over 3 to 5 minutes. the infant should be kept warm so that his respiratory distress isn't aggravated. Hypomagnesemia isn¶t a complication of preeclampsia. A digital or speculum examination shouldn¶t be done as this may lead to severe bleeding or hemorrhage. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Amniocentesis is contraindicated in placenta previa. The area must be a raised wheal. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper. and L. Answer: (C) I. Answer: (A) 110 to 130 calories per kg. Answer: (A) conjoined twins Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of the ovum occurs. The expiratory volume and residual volume decrease as the pregnancy progresses. 85. . Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Magnesium doesn¶t help prevent hemorrhage in preeclamptic clients. 92. Fluids. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks¶ gestation. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen. Naloxone is used to correct narcotic toxicity. which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. 89. so there¶s some growth retardation in twins if they remain in utero at 38 to 40 weeks.V.84. Ten milliliters of 10% calcium gluconate is given L. not a flat circumcised area to be considered positive. Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen.V.

and thin lips are seen in infants with fetal alcohol syndrome. Uterine involution and some uterine discomfort are normal after delivery. 7. extended labor stimulation with oxytocin. The client will see only from the right side. 98. Lethargy isn't associated with neonatal heroin addiction. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. Signs of heroin withdrawal include irritability. which may lead to postpartum hemorrhage. fetal hypoxia. leading to maternal hypotension and. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis. the therapeutic level is 1. Answer: (A) On the client¶s right side Rationale: The client has left visual field blindness. of if the phone is not available. Rationale: The significant effect of nitroglycerin is vasodilation and decreased venous return. The squatting position promotes comfort by taking advantage of gravity. Answer: (B) Irritability and poor sucking. Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. Rationale: Having established. position improves maternal and fetal circulation. Answer: (B) Rh-positive fetal blood crosses into maternal blood. and suprapubic tenderness. and a neck injury should be suspected. Noting the time is important baseline information for cardiac arrest procedure. reduces muscle tension. This may be done by dialing the operator from the client¶s phone and giving the hospital code for cardiac arrest and the client¶s room number to the operator. so the heart does not have to work hard. Answer: (B) Uterine atony Rationale: Multiple fetuses.95. in turn. and traumatic delivery commonly are associated with uterine atony. 6. or will neutralize and buffer the acid that does accumulate. Answer: (A) Call for help and note the time. For instance. frequency. that the client is unconscious rather than sleep. 100. the nurse should immediately call for help. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. and restlessness. 2. Asymptomatic bacteriuria doesn¶t cause symptoms. inhibits maternal circulation. Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid. Answer: (C) Check respirations. 99. enhances comfort. urgency. Answer: (B) Continue treatment as ordered. and eliminates pressure points. 5. Answer: (C) Make sure that the client takes food and medications at prescribed intervals. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. by stimulating the client. Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds.5 to 2 times the normal level. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Heroin use during pregnancy hasn't been linked to specific congenital anomalies. The stool consistency is related to how much water is being absorbed. This is known as subinvolution. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. bloody Rationale: Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. This. TEST III Answers and Rationale ± Care of Clients with Physiologic and Psychosocial Alterations 1. the lateral. or side-lying. by pulling the emergency call button. poor sucking. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. 96. a serious condition in a pregnant client. Answer: (C) Loose. A flattened nose. UTI symptoms include dysuria. ultimately. stabilize spine. stimulating maternal antibodies. 3. 97. maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. The other positions promote comfort and aid labor progress. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. 4. small eyes. increases maternal relaxation. and check circulation Rationale: Checking the airway would be priority. Answer: (D) Decreasing venous return through vasodilation. . In subsequent pregnancies with Rh-positive fetuses.

Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Answer: (D) Decreased vital capacity Rationale: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs. Answer: (C) The client is oriented when aroused from sleep.9°C). Estrogen deficiencies result from menopause-not osteoporosis. By keeping the client flat. the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. and photophobia aren¶t usual TB symptoms. 20. Answer: (B) In the operating room. 10. which avoids trauma to the neurons. Dowager¶s hump results from bone fractures. Rationale: Lidocaine drips are commonly used to treat clients whos arrhythmias haven¶t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. acetaminophen should be used to pain relief. 16. blood pressure. but isn¶t effect of taking an anticoagulant. and an increased in residual volume. Rationale: The stoma drainage bag is applied in the operating room. SaO2. Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Answer: (A) Bone fracture Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones. 21. Nausea. headache. 12. 9. The client may need to report diarrhea. fever. 19. areas of thickness or fullness that signal the presence of a malignancy. It develops when repeated vertebral fractures increase spinal curvature. Only a physician can diagnose lumps that are cancerous. . An electric razornot a straight razor-should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding. 13. Calcium and vitamin D supplements may be used to support normal bone metabolism. Answer: (B) Respiratory arrest Rationale: Narcotics can cause respiratory arrest if given in large quantities. Answer: (B) Avoid foods high in vitamin K Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. and pleuritic chest pain are the common symptoms of pneumonia. Protection of the skin from the effects of these enzymes is begun at once. or masses that are fibrocystic as opposed to malignant. and excoriated. fewer functional capillaries in the alveoli. But a negative calcium balance isn¶t a complication of osteoporosis. Rationale: This finding suggest that the level of consciousness is decreasing. It¶s unlikely the client will have asthma attack or a seizure or wake up on his own. Skin exposed to these enzymes even for a short time becomes reddened. hemortysis. fever. cerebral spinal fluid pressures are equalized. He¶s unlikely to have bronchial pneumonia without a productive cough and fever and he¶s too young to have developed (COPD) and emphysema. Chest pain may be present from coughing. painful. and ICP are important factors but aren¶t as significant as PVCs in the situation. 15. night sweats. Rationale: Women are instructed to examine themselves to discover changes that have occurred in the breast. Rationale: To avoid the complication of a painful spinal headache that can last for several days. 14. Clients with TB typically have low-grade fevers. Answer: (B) Flat on back. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Answer:(A) Acute asthma Rationale: Based on the client¶s history and symptoms. 11. 18. dyspnea. and hemoptysis Rationale: Typical signs and symptoms are chills.8. Answer: (C) Balance the client¶s periods of activity and rest. but isn¶t usual. but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response. chills. Answer: (B) Chills. acute asthma is the most likely diagnosis. cough. Answer: (A) Altered mental status and dehydration Rationale: Fever. 17. Shaving the area can cause skin abrasions and depilatories can irritate the skin. Answer: (C) Changes from previous examinations. and goes back to sleep immediately. night sweats. Answer: (C) Clipping the hair in the area Rationale: Hair can be a source of infection and should be removed by clipping. and hemoptysis. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor. not higher than 102°F (38.

22. Answer: (B) Increase his activity level. Rationale: The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 23. Answer: (A) Laminectomy Rationale: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. 24. Answer: (D) Avoiding straining during bowel movement or bending at the waist. Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) ± not 5lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. 25. Answer: (D) Before age 20. Rationale: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular selfexamination before age 20, preferably when he enters his teens. 26. Answer: (B) Place a saline-soaked sterile dressing on the wound. Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client¶s vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. 27. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods. Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by shallower respirations with apneas periods. Biot¶s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Kussmaul¶s respirationa are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate. 28. Answer: (B) Fine crackles Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. 29. Answer: (B) The airways are so swollen that no air cannot get through Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can¶t get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an acute asthma attack. 30. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head. Rationale: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. 31. Answer: (B) Kinked or obstructed chest tube Rationales: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won¶t cause a tension pneumothorax. Excessive water won¶t affect the chest tube drainage. 32. Answer: (D) Stay with him but not intervene at this time. Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone. 33. Answer: (B) Current health promotion activities Rationale: Recognizing an individual¶s positive health measures is very useful. General health in the previous 10 years is important, however, the current activities of an 84 year old client are most significant in planning care. Family history of disease for a client in later years is of minor significance. Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. 34. Answer: (C) Place the client in a side lying position, with the head of the bed lowered. Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used. 35. Answer: (C) Pneumonia

Rationale: Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn¶t having an MI. the client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse¶s suspicions. 36. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism Rationale: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB. A high school student, daycare worker, and businessman probably have a much low risk of contracting TB. 37. Answer: (C ) To determine the extent of lesions Rationale: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest X-ray can¶t determine if this is a primary or secondary infection. 38. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first line of treatment for asthma because broncho-constriction is the cause of reduced airflow. Betaadrenergic blockers aren¶t used to treat asthma and can cause bronchoconstriction. Inhaled oral steroids may be given to reduce the inflammation but aren¶t used for emergency relief. 39. Answer: (C) Chronic obstructive bronchitis Rationale: Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema. 40. Answer: (A) The patient is under local anesthesia during the procedure Rationale: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia. 41. Answer: (D) Raise the side rails Rationale: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety. 42. Answer: (A) Crowd red blood cells Rationale: The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur. 43. Answer: (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone marrow, spleen and liver. 44. Answer: (A) Explain the risks of not having the surgery Rationale: The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client¶s refusal in the nurses¶ notes. 45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don¶t require immediate attention). The lowest priority is the 89-year-old with endstage right-sided heart failure, who requires time-consuming supportive measures. 46. Answer: (C) Cocaine Rationale: Because of the client¶s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. 47. Answer: (B) Nonmobile mass with irregular edges Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction ² not eversion ² may be a sign of cancer. 48. Answer: (C) Radiation

Rationale: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer. 49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3. 50. Answer: (D) "Keep the stoma moist." Rationale: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. 51. Answer: (B) Lung cancer Rationale: Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma. 52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus. 53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer. Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect. 54. Answer: (D) "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria. 55. Answer: (C) Sigmoidoscopy Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer. 56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. 57. Answer: (A) Liver Rationale: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and
brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

58. Answer: (D) The client wears a watch and wedding band. Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull
on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field.

59. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods.
Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures.

60. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure. 61. Answer: (D) Gouty arthritis Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees. 62. Answer: (B) 30 ml/hou Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour. 63. Answer: (B) Loss of muscle contraction decreasing venous return Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but don¶t appear with swelling. DVT may develop in clients with a stroke but is more likely to occur in the lower extremities. A stroke isn¶t linked to protein loss. 64. Answer: (B) It appears on the distal interphalangeal joint Rationale: Heberden¶s nodes appear on the distal interphalageal joint on both men and women. Bouchard¶s node appears on the dorsolateral aspect of the proximal interphalangeal joint. 65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isn¶t gender-specific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders. 66. Answer: (C) The cane should be used on the unaffected side Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints. 67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin. 68. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. 69. Answer: (A) Adrenal cortex Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines ² epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. 70. Answer: (C) They debride the wound and promote healing by secondary intention Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing. 71. Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

72. Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load. 73. Answer: (D) glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. 74. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m. 75. Answer: (A) Glucocorticoids and androgens Rationale: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines ² epinephrine and norepinephrine. 76. Answer: (A) Hypocalcemia Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery. 77. Answer: (D) Carcinoembryonic antigen level Rationale: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer. 78. Answer: (B) Dyspnea, tachycardia, and pallor Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction. 79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby." Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative. 80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors." Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS. 81. Answer: (B) Pallor, tachycardia, and a sore tongue Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. 82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority.

Answer: (C) stool for Clostridium difficile test. Aspirin doesn't lead to weight gain or fine motor tremors. Answer: (B) Warm the dialysate solution. the potential need for a transfusion increases. Successful treatment begins with an accurate diagnosis. Blood glucose levels. 91. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea. Rationale: The client is at risk for peritonitis. 90. Rationale: Using comfort measures and pillows to position the client is a non-pharmacological methods of pain relief. 84. Rationale: HIV infection is detected by analyzing blood for antibodies to HIV. The Western blot test ² electrophoresis of antibody proteins ² is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. thrombin time. Rationale: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad. GI tract. ³I have a funny feeling in my right leg. Large or toxic salicylate doses may cause respiratory alkalosis. requires immediate assessment. client complaints of chills. ears. it doesn't confirm HIV infection. 93. Brazil nuts. a positive ELISA result must be confirmed by the Western blot test. platelet count. The neutrophil is crucial to phagocytosis. 94. The basophil plays an important role in the release of inflammatory mediators. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. which form approximately 2 to 12 weeks after exposure to HIV and denote infection. and oranges rarely cause allergic reactions. this adverse effect resolves within 2 weeks after the therapy is discontinued. . 95. not electrolytes. Arrhythmias aren't a problem associated with Sjogren's syndrome. Rationale: Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin. Moisture replacement is the mainstay of therapy. Rationale: Immunosuppressed clients ² for example. not respiratory acidosis. shellfish. cashews. it isn't the predominant problem. Erosette immunofluorescence is used to detect viruses in general. peanuts. should be assessed for further symptoms and infection. which includes a stool test. WBC count. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. Answer: (D) Lymphocyte Rationale: The lymphocyte provides adaptive immunity ² recognition of a foreign antigen and formation of memory cells against the antigen. which causes "horse barn" smelling diarrhea. Answer: (A) moisture replacement. Urine constituents aren't found in the blood. don¶t use microwave oven.´ Rationale: It may indicate neurovascular compromise. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. and partial thromboplastin time Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time. Answer: (D) Western blot test with ELISA. 86. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. Answer: (D) Use comfort measures and pillows to position the client. nose. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago. partial thromboplastin time. and fibrinogen level as well as client history and other assessment factors. and potassium levels aren't used to confirm a diagnosis of DIC. 88. Rationale: Carpal spasms indicate hypocalcemia.83. 85. ² are at risk for infection with C. clients receiving chemotherapy. carrots. and vagina. Answer: (D) bilateral hearing loss. Bread. Coagulation is determined by the presence of appropriate clotting factors. Answer: (B) A client with cast on the right leg who states. calcium levels. Rationale: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained. The monocyte functions in phagocytosis and monokine production. 89. 92. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract. Answer: (D) Strawberries Rationale: Common food allergens include berries. and eggs. prothrombin time. difficile. Possible renal failure is indicated by elevated BUN or creatinine levels. Usually. If the HCT and Hb levels decrease during surgery because of blood loss. Answer: (A) Platelet count. The ELISA test detects HIV antibody particles but may yield inaccurate results. 87.

3. Answer: (B) Keep the irrigating container less than 18 inches above the stoma. 99. moves the cane forward followed by the right leg. along with fever. This will prevent trauma to the area of the pacemaker generator. 98. 7.´ Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated. severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm. 100. reducing the serum potassium level. Left lower extremity 18%. Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation. Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy. Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg. Answer: (A) Pain Rationale: Sharp. 9. Answer: (D) Decrease the size and vascularity of the thyroid gland. relief form pain is the priority. 13. 11. Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. Answer: (B) The client lifts the walker. 4. Posterior trunk 18%. Answer:(B) 28 gtt/min Rationale: This is the correct flow rate. placed down on all legs. Anterior trunk 18%. TEST IV Answers and Rationale ± Care of Clients with Physiologic and Psychosocial Alterations 1. permits sodium to be exchanged for potassium in the intestine. . reflects acute rejection. Giving the client oxygen in low concentrations will maintain the client¶s hypoxic drive. 97. increased intracranial pressures. Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing. Answer: (D) may engage in contact sports Rationale: The client should be advised by the nurse to avoid contact sports. Answer: (C) Leukopenia Rationale: Leukopenia. Answer: (D) Upper trunk Rationale: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%. Answer: (C) The client holds the cane with his left hand. Rationale: A walker needs to be picked up. Answer: (A) Liver Disease Rationale: The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen. Answer: (A) Encourage the client to perform pursed lip breathing. 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) 10. and taste interferes with normal functioning. Answer: (C) Isolation from their families and familiar surroundings. 5. 12. Rationale: Gradual loss of sight. and tenderness over the grafted kidney.a potassium exchange resin. 6. Answer: (A) Administer Kayexalate Rationale: Kayexalate. Left upper extremity 9%. which aids in decreasing the vascularity of the thyroid gland. 8. 2. Answer: (C) Bleeding from ears Rationale: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function. which limits the risk of hemorrhage when surgery is performed. Perineum 1%. and then takes several small steps forward. hearing. fractures and bleeding. is a systemic effect of chemotherapy as a result of myelosuppression. Rationale: Lugol¶s solution provides iodine. Answer: (C) Avoid foods that in the past caused flatus. Right upper extremity 9%. The hypoxic state of the client then becomes the stimulus for breathing. a reduction in WBCs. Answer: (C) Hypertension Rationale: Hypertension. and then moves the left leg. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. moves it forward 10 inches. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.96. Right lower extremity 18%. Answer: (A) Ask the woman¶s family to provide personal items such as photos or mementos.

shape.7 to 1. 22.8 cm (2" to 2. Yearly Pap smears are very important for early detection.5 mg/dl. oropharynx. prone with the torso elevated. Answer: (A) Auscultate bowel sounds. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6. there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. and phosphorous. the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Answer: (B) Facilitate ventilation of the left lung. 16. or sodium bicarbonate. such as the mouth. the nurse initially should position the client on the left side with knees bent. The administration of glucose and regular insulin. insulin. and organization of differentiated cells. The kidneys are located retroperitoneally. reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. Answer: (D) Alteration in the size. It's life-threatening if immediate action isn't taken to reverse it.7 mg/dl. a condom won't protect sexual partners. and organization of differentiated cells Rationale: Dysplasia refers to an alteration in the size. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage Rationale: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. she should have a Papanicolaou (Pap) smear annually. If peristalsis is absent. Rationale: If abdominal distention is accompanied by nausea. 5 to 5. Palpation should be avoided postoperatively with abdominal distention. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate.5 mg/dl falls within the normal range of 2. shape. 15. and 2. 23. Answer: (B) Lying on the left side with knees bent Rationale: For a colonoscopy. They lie between the 12th thoracic and 3rd lumbar vertebrae. or cardiac arrhythmias. 17.5 cm (1") thick. Rationale: Since only a partial pneumonectomy is done. 18. A uric acid analysis of 3. multiple myeloma. Because condylomata acuminata can occur on the vulva.7 to 7. and decreases serum levels of calcium. and larynx. Rationale: Hyperkalemia is a common complication of acute renal failure.14. CRF causes decreased pH and increased hydrogen ions ² not vice versa. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia. Answer: (A) Food and fluids will be withheld for at least 2 hours. Because condylomata acuminata is a virus. the normal serum creatinine level ranges from 0. 21. 19. there is no permanent cure. Answer: (C) hyperkalemia. on either side of the vertebral column. 20. magnesium. changing positions and inserting a rectal tube won't relieve the client's discomfort. can temporarily prevent cardiac arrest by moving tassium into the cells and temporarily reducing serum potassium levels. Answer: (A) The left kidney usually is slightly higher than the right one. seizures.") wide. in the posterior aspect of the abdomen. The test results in option C are abnormally elevated. Placing the client on the right side with legs straight. Answer: (A) This condition puts her at a higher risk for cervical cancer. Proper positioning doesn't help prevent confusion.5 mg/dl. If bowel sounds are absent. Rationale: The left kidney usually is slightly higher than the right one. PSP excretion of 75% also falls with the normal range of 60% to 75%. An adrenal gland lies atop each kidney. the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. 25. with sodium bicarbonate if necessary. Rationale: The normal BUN level ranges 8 to 23 mg/dl. hypokalemia. Hypernatremia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Answer: (D) Kaposi's sarcoma Rationale: Kaposi's sarcoma is the most common cancer associated with AIDS. HPV can be transmitted to other parts of the body. The average kidney measures approximately 11 cm (4-3/8") long. therefore. Rationale: Prior to bronchoscopy. and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose. Squamous cell carcinoma. Answer: (A) Blood supply to the stoma has been interrupted . or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine. and leukemia may occur in anyone and aren't associated specifically with AIDS. Rationale: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. CRF also increases serum levels of potassium. 24. The gag reflex usually returns after two hours. the nurse must first auscultate bowel sounds.

and downward strokes in the direction of hair growth. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. also decreasing the workload of the heart. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Answer: (A) Turn him frequently. not visible). Answer: (B) Urine output of 20 ml/hour. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit. Answer: (A) Beta -adrenergic blockers Rationale: Beta-adrenergic blockers work by blocking beta receptors in the myocardium. Answer: (C) Raised 30 degrees Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. If pressure isn't relieved. Diuretics are administered to decrease the overall vascular volume. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. indicating adequate arterial perfusion. Answer: (C) In long. Narcotics reduce myocardial oxygen demand. reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. 28. which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. This application pattern reduces the risk of follicle irritation and skin inflammation. and decrease anxiety. capillaries become occluded. outward. 29. Increased pressure can¶t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). Answer: (B) Less than 30% of calories form fat Rationale: A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. Answer: (D) Inotropic agents Rationale: Inotropic agents are administered to increase the force of the heart¶s contractions. even. White pulmonary secretions also are normal. creating an artificial opening for waste elimination. the veins would be barely discernible above the clavicle. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload). 30. The other modifications are appropriate for this client. 31. but not in the legs. During passive ROM exercises. Rationale: The most important intervention to prevent pressure ulcers is frequent position changes. In high Fowler¶s position. Answer: (C) The emergency department nurse calls up the latest electrocardiogram results to check the client¶s progress Rationale: The emergency department nurse is no longer directly involved with the client¶s care and thus has no legal right to information about his present condition. 33. Rationale: A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. The stoma should appear cherry red. An intestinal obstruction also wouldn't change stoma color. A dusky stoma suggests decreased perfusion. 26. which relieve pressure on the skin and underlying tissues. 34. Adjusting the ostomy bag wouldn't affect stoma color. even. 27. doing so doesn¶t breach confidentiality. . promote vasodilation. outward. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders. They protect the myocardium. Answer: (A) Applying knee splints Rationale: Applying knee splints prevents leg contractures by holding the joints in a position of function. reducing the response to catecholamines and sympathetic nerve stimulation. which depends on blood supply to the area. Because the client requested that the nurse update his wife on his condition. thereby increasing ventricular contractility and ultimately increasing cardiac output. which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. and downward strokes in the direction of hair growth Rationale: When applying a topical agent.Rationale: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin. A dusky stoma isn't a normal finding. helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. the nurse moves each joint through its range of movement. 32. the nurse should begin at the midline and use long.

allogeneic transplant is between two humans. Moreover. Rationale: An electrocardiogram evaluates the complaints of chest pain. Answer: (D) Breath sounds Rationale: Pneumonia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload. Pericarditis isn¶t associated with Hodgkin¶s disease. neither is common in a client after revascularization surgery. the nurse should make sure L. and autologous is a transplant from the same individual.35. and generalized pruritis. 39. Cardiac monitoring. Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT) Rationale: HATT may occur after CABG surgery due to heparin use during surgery. 42. night sweats are generally more prevalent. Although assessing blood pressure. both viral and fungal. Answer: (B) Rationale: Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. An electroencephalogram evaluates brain electrical activity. Calcium is released to assist the conversion of factors X to Xa. 40. Methotrexate can cause thrombocytopenia. Answer: (B) Check endotracheal tube placement. testing for occult blood. fibrinogen and fibrin split products are measured to verify bleeding dyscrasias. partial thromboplastin time. symptoms include a single enlarged lymph node (usually). Then the nurse should try to find the cause of the client¶s arrest by obtaining an ABG sample.V. 36. and the stool test for occult blood determines blood in the stool. and heart sounds is important. Next. Answer: (D) Xenogeneic Rationale: An xenogeneic transplant is between is between human and another species. complete blood count. laboratory tests determines anemia. bowel sounds. so frequent assessment of respiratory rate and breath sounds is required. it won¶t help detect pneumonia. The disorder known as von Willebrand¶s disease is a type of hemophilia and isn¶t linked to SLE. unexplained fever. Persistent hypothermia is associated with Hodgkin¶s but isn¶t an early sign of the disease. Prothrombin time. A syngeneic transplant is between identical twins. Answer: (C) Essential thrombocytopenia Rationale: Essential thrombocytopenia is linked to immunologic disorders. ventricular fibrillation and atrial flutter ± not symptomatic bradycardia. night sweats. oxygen. Although splenomegaly may be present in some clients. 41. atropine is administered as ordered 0. Answer: (C) 95 mm Hg Rationale: Use the following formula to calculate MAP MAP = systolic + 2 (diastolic) 3 MAP=126 mm Hg + 2 (80 mm Hg) 3 MAP=286 mm HG 3 MAP=95 mm Hg 37. nor is hypothermia. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Conversion of factors XII to XIIa and VIII to VIIIa are part of the intrinsic pathway. such as SLE and human immunodeficiency vitus. Answer: (B) Corticosteroids Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets. Rationale: ET tube placement should be confirmed as soon as the client arrives in the emergency department. and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. malaise. Once the airways is secured. Although DIC and ITP cause platelet aggregation and bleeding. and ASA decreases platelet aggregation. access is established. is a common cause of death in clients with neutropenia. Pancytopenia is a reduction in all blood cells. oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. not polycythermia. splenomegaly and pericarditis aren¶t symptoms. 43. Answer: (C) Electrocardiogram. Amiodarone is indicated for ventricular tachycardia. retaining more functioning platelets. comprehensive serum metabolic panel. Answer: (B) Muscle spasm . 38. Dressler¶s syndrome is pericarditis that occurs after a myocardial infarction and isn¶t linked to SLE. Moderate to severe anemia is associated with SLE. If the client experiences symptomatic bradycardia. 45. 44.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Answer: (B) Night sweat Rationale: In stage 1.

and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance. the recipient develops anti-Rh agglutinins. fatigue. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed. hence the term ³puffer. Answer: (C) Immediately discontinue the infusion Rationale: Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. Answer: (D) ³This is only temporary. 56.´ Clients with ARDS are usually acutely short of breath. resulting in microthrombi and excessive bleeding. which reflect parts of the nervous system. 52. When the patient is already comfortable. Answer: D 80 mm Hg Rationale: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. Rationale: This is the appropriate response. it is still of the same color and texture. Answer: (D) Hodgkin¶s disease Rationale: Hodgkin¶s disease typically causes fever night sweats. weight loss. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Answer: (C) Respiratory acidosis . and clients with emphysema appear pink and cachectic. Answer: (D) Emphysema Rationale: Because of the large amount of energy it takes to breathe. All other values are lower than expected. 49. They¶re pink and usually breathe through pursed lips. they have large barrel chest and peripheral edema. The other manifestations are expected side effects of chemotherapy. The value expected would be around 80 mm Hg. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. 50.Rationale: Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. platelets and clotting factors are consumed. The nurse should help the mother how to cope with her own feelings regarding the child¶s disease so as not to affect the child negatively. Persons with the D antigen have Rhpositive blood type. clients with emphysema are usually cachectic. weight loss or lymph node enlargement. Fibrin degeneration products increase as fibrinolysis takes places. those lacking the antigen have Rh-negative blood. Answer: (C)10 years Rationale: Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years. but may be different in texture´. Stacy will re-grow new hair in 3-6 months. 53. and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. 51. It¶s important that a person with Rhnegative blood receives Rh-negative blood. Answer: (C) A Rh-negative Rationale: Human blood can sometimes contain an inherited D antigen. Rationale: Persistent (more than 24 hours) vomiting. As clots form. Influenza doesn¶t last for months. 48. and decreased tolerance for exercise. anorexia. Every 2-4 hours. The other options. Rationale: Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. If Rh-positive blood is administered to an Rh-negative person. 55. and lymph mode enlargement. the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Answer: (C) Chronic obstructive bronchitis Rationale: Clients with chronic obstructive bronchitis appear bloated. and at times. and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells. 46. Clients with asthma don¶t have any particular characteristics. 54. When the hair grows back. The patient feels pain as the nerves are irritated by pressure and the IV solution. 57. circumoral cyanosis. night sweats. fibrinogen levels decrease and the prothrombin time increases. 47. Leukemia doesn¶t cause lymph node enlargement. Clients with asthma don¶t exhibit characteristics of chronic disease. aren¶t usually affected by MM. Answer: (B) ³I will call my doctor if Stacy has persistent vomiting and diarrhea´. they don¶t show fever. Answer: (A) Low platelet count Rationale: In DIC. cyanotic nail beds.

Lactulose is also very sweet and may cause cramping and bloating. Answer: (C) Kidneys¶ excretion of sodium and water Rationale: The kidneys respond to rise in blood pressure by excreting sodium and excess water. elevated antinuclear antibody (ANA) titer . so blood pressure wouldn¶t increase. Answer: (D) Elevated serum aminotransferase Rationale: Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT). decreased blood pressure. the client has respiratory acidosis. directly relaxing vascular smooth muscle and decreasing blood pressure. secondary to pressure being applied within the abdominal cavity. The WBC count increases as cell migrate to the site of injury. Sodium and water travel together across the membrane in the kidneys. Anaphylactic shock results from an allergic reaction. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to normal. vital signs assessment is important. HCO3. For the same reason. 60. Answer: (C) ³I¶ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day´.was below 22 mEq/L the client would have metabolic acidosis. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. 66. Answer: (B) Severe lower back pain. The stool will be mashy or soft. which eliminates metabolic and respiratory alkalosis as possibilities. Rationale: Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. 58. The pH is less than 7. 65. academic. Vasodilators cause dilation of peripheral blood vessels. thereby causing a decrease in blood pressure. 64. Rationale: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle. in case a clot has formed. Answer: (D) Apply gloves and assess the groin site Rationale: Observing standard precautions is the first priority when dealing with any blood fluid. consider the new drug first.35. Answer: (C) Respiratory failure Rationale: The client was reacting to the drug with respiratory signs of impending anaphylaxis. The nurse would call for help if it were warranted after the assessment of the situation. the vasculature is interrupted and blood volume is lost. After determining the extent of the bleeding. This response ultimately affects sysmolic blood pressure by regulating blood volume. After the aneurysm ruptures. Answer: (B) Cardiogenic shock Rationale: Cardiogenic shock is shock related to ineffective pumping of the heart. This results in accumulation of ammonia and other toxic in the blood that damages the cells. Assessment of the groin site is the second priority. 61. 68. increased WBC count. the RBC count is decreased ± not increased. Answer: (B) Altered level of consciousness Rationale: Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Rheumatoid arthritis doesn¶t manifest these signs. 67. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle. If the patient experience diarrhea. This establishes where the blood is coming from and determines how much blood has been lost. Blood pressure decreases due to the loss of blood. which could lead to eventually respiratory failure. Sodium or water retention would only further increase blood pressure. 69. decreased RBC count. The nurse should never move the client. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA) Rationale: PTCA can alleviate the blockage and restore blood flow and oxygenation. Nitroglycerin is an oral sublingual medication. Answer: (C) Pancytopenia. If the HCO3. An echocardiogram is a noninvasive diagnosis test. Rationale: Severe lower back pain indicates an aneurysm rupture. Cardiac catheterization is a diagnostic tool ± not a treatment. 62. 63. Moving can disturb the clot and cause rebleeding. MI isn¶t a shock state. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Although the signs are also related to an asthma attack or a pulmonary embolism.Rationale: Because Paco2 is high at 80 mm Hg and the metabolic measure. though a severe MI can lead to shock. Answer: (A) Impaired clotting mechanism Rationale: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism. 59. it indicates over dosage and the nurse must reduce the amount of medication given to the patient. the pain is constant because it can¶t be alleviated until the aneurysm is repaired. When ruptured occurs. one can¶t travel without the other. The goal in this situation is to stop the bleeding.

they don't have bone pain and increased sleeping. two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. is associated with hypothyroidism but isn't life-threatening. Dry mucous membranes and frequent urination signal dehydration. thereby masking changes in his level of consciousness. Rationale: Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn¶t acetaminophen is strong enough ignores the mother¶s question and therefore isn¶t appropriate. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. 77. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. 78. protrusion of the eyeballs. Answer: (B) An irregular apical pulse Rationale: Because Cushing's syndrom0e causes aldosterone overproduction. with disorder of airways. Tibial myxedema. Aspirin is contraindicated in conditions that may have bleeding. above-normal serum osmolality level Rationale: In diabetes insipidus. resulting in a below-normal urine osmolality level. Clients also exhibit hypercaliuria-causing polyuria. although most are elderly. or eat more than usual. Exophthalmos. such as an irregular apical pulse." Rationale: Hydrocortisone. There¶s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. breathing. Clients may have elevated BUN and creatinine levels from nephritis. a glucocorticoid. and decreased serum complement levels. excessive polyuria causes dilute urine. the disorder may lead to hypokalemia. peripheral mucinous edema involving the lower leg. It can afflict people of any age. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate. polydipsia. 74. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. A highcarbohydrate diet would exacerbate the client's condition. such as trauma. drink. therefore. polyuria depletes the body of water. decrease infection. Answer: (D) Below-normal urine osmolality level. Alveolar hypoventilation would be reflected in an increased Paco2. The order of client assessment should follow client priorities. Hypoparathyroidism is characterized by urinary frequency rather than polyuria. causing dehydration that leads to an abovenormal serum osmolality level." Rationale: Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) Rationale: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties. 75. but the increase does not indicate SLE. the client may prevent HHNS. Answer: (C) Myxedema coma Rationale: Myxedema coma. and for children or young adults with viral illnesses due to the danger of Reye¶s syndrome. . For the same reasons. Oxygenation is evaluated through Pao2 and oxygen saturation. lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. 71. By recognizing the signs of hyperglycemia (polyuria. 72. to the physician. At the same time.Rationale: Laboratory findings for clients with SLE usually show pancytopenia. and polyphagia) and increasing fluid intake. diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. which increases urinary potassium loss. Answer: (D) Hyperparathyroidism Rationale: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). therefore. the nurse should immediately report signs and symptoms of hypokalemia. or decrease bone demineralization. severe hypothyroidism. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon. Answer: (A) Appropriate. Answer: (C) Narcotics are avoided after a head injury because they may hide a worsening condition. This dosage schedule reduces adverse effects. Stronger medications may not necessarily lead to vomiting but will sedate the client. Therefore. is a life-threatening condition that may develop if thyroid replacement medication isn't taken. 73. should be administered according to a schedule that closely reflects the body's own secretion of this hormone. 80. While clients with diabetes mellitus and diabetes insipidus also have polyuria. 70. Answer: (C) Osteoarthritis is the most common form of arthritis Rationale: Osteoarthritis is the most common form of arthritis and can be extremely debilitating. elevated ANA titer. 76. which isn't associated with Cushing's syndrome. particularly if fluid intake is low. Answer: (C) Decreases inflammation Rationale: Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome Rationale: Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. is seen with hyperthyroidism. 79. and then circulation. There¶s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care. Colchicine doesn¶t replace estrogen.

Metabolic acidosis.m. Answer: (D) Below-normal serum potassium level Rationale: A client with HHNS has an overall body deficit of potassium resulting from diuresis. hyperglycemic state caused by the relative insulin deficiency. 85. 83. It¶s unlikely the client has developed asthma or bronchitis without a previous history. brittle. nerves. Answer: (C) High corticotropin and high cortisol levels Rationale: A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. such as heat intolerance. isn't at risk for ketosis. Answer: (A) Adult respiratory distress syndrome (ARDS) Rationale: Severe hypoxia after smoke inhalation is typically related to ARDS. humerus. Urine specific gravity isn't indicated because although fluid balance can be compromised. He could develop atelectasis but it typically doesn¶t produce progressive hypoxia. placing the client at risk for hyperglycemia. Insulin should be injected only into healthy tissue lacking large blood vessels. Sodium and potassium aren't involved in the development of osteoporosis. which cause shortness of breath and hypoxia. 84.. also. Below-normal levels of T3 and T4. signal hypothyroidism. intake of oral fluids. such as from a fall on an outstretched hand. failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. the nurse should keep the client's room temperature in the low-normal range. bones lose calcium and phosphate salts. to prevent lipodystrophy. so the client shouldn't inject insulin into sites above muscles that will be exercised heavily. and abnormally vulnerable to fracture.m. diaphoresis.81. Answer: (A) Fracture of the distal radius Rationale: Colles' fracture is a fracture of the distal radius. or carpal scaphoid. Answer: (B) Calcium and phosphorous Rationale: In osteoporosis. the expected onset would be from 2:15 p. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. Answer: (D) Maintaining room temperature in the low-normal range Rationale: Graves' disease causes signs and symptoms of hypermetabolism. has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. To replace fluids lost via diaphoresis. insulin absorption differs from one region to the next. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs. not among different regions. it usually isn't dangerously imbalanced. may occur in HHNS. 91.m. not serum alkalosis. the nurse should encourage.m.m. becoming porous. 90. Exercise speeds drug absorption. which is a short-acting insulin. 82. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy). An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. The other conditions listed aren¶t typically associated with smoke inhalation and severe hypoxia. To reduce heat intolerance and diaphoresis. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection. 87. as detected by radioimmunoassay. . A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Injecting insulin into areas of hypertrophy may delay absorption. It's most common in women. to 6 p. A decreased TSH level indicates a pituitary deficiency of this hormone.m. which occurs secondary to the hyperosmolar. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level. Answer: (C) onset to be at 2:30 p. therefore. Rationale: Regular insulin. and weight loss. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. Answer: (B) "Rotate injection sites within the same anatomic region. the nurse should encourage the client to eat highcarbohydrate foods. 86. excessive thirst and appetite. Because the nurse gave the insulin at 2 p. Answer: (D) Performing capillary glucose testing every 4 hours Rationale: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test Rationale: In the TSH test. 89.m. or scar tissue or other deviations. to 2:30 p." Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region. and the peak from 4 p. Urine ketone testing isn't indicated because the client does secrete insulin and. Colles' fracture doesn't refer to a fracture of the olecranon. 88. and its peak to be at 4 p. Answer: (D) Fat embolism Rationale: Long bone fractures are correlated with fat emboli. the client should rotate injection sites systematically. To provide needed energy and calories. not restrict.

7. Answer: (D) Remove all other clients from the dayroom. Answer: (C) Agree to talk with the mother and the father together. although a temporary mediastinal shift exits until the space is filled. Rationale: Group activity provides too much stimulation. which the client will not be able to handle (harmful to self) and as a result will be disruptive to others. 6. 100. 95. Answer: (D) Spontaneous pneumothorax Rationale: A spontaneous pneumothorax occurs when the client¶s lung collapses. TEST V Answers and Rationale ± Care of Clients with Physiologic and Psychosocial Alterations 1. 97. it¶s unlikely he has bronchitis. Answer: (D) Focusing Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. 96. Answer: (A) Alveolar damage in the infracted area Rationale: The infracted area produces alveolar damage that can lead to the production of bloody sputum. Answer: (A) The client is disruptive. 5. In pneumothorax an air leak can occur as air is pulled from the pleural space. pneumonia. 98.92. Answer: (A) Air leak Rationale: Bubbling in the water seal chamber of a chest drainage system stems from an air leak. The sudden collapse was the cause of his chest pain and shortness of breath. Answer: (A) Perceptual disorders. The other actions are appropriate responses after ensuring the safety of other clients. 94. There¶s no gel that can be placed in the pleural space. Answer: (C) Pneumothorax Rationale: From the trauma the client experienced. Answer: (B) 21 Rationale: 3000 x 10 divided by 24 x 60.12mg/ x ml. Answer: (C) Superego Rationale: This behavior shows a weak sense of moral consciousness. Answer: (D) Respiratory alkalosis Rationale: A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide. preventing extensive mediastinal shift of the heart and remaining lung. Rationale: The client needs a specific response. x = 2. make observation. or ask further question (exploring). Answer: (D) Suggest that it takes awhile before seeing the results. 2. Bubbling doesn¶t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber. Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. bronchial breath sounds with TB would be heard. causing an acute decreased in the amount of functional lung used in oxygenation. that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached. which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis. . Answer: (C) Serous fluids fills the space and consolidates the region Rationale: Serous fluid fills the space and eventually consolidates.05x = . or TB. 99. The tissue from the other lung can¶t cross the mediastinum.12. Clot formation usually occurs in the legs. Rationale: By agreeing to talk with both parents. . An asthma attack would show wheezing breath sounds. Pneumonia would have bronchial breath sounds over the area of consolidation. Rationale: The nurse¶s first priority is to consider the safety of the clients in the therapeutic setting.4 ml. 4.4 ml Rationale: . personality disorders stem from a weak superego. The nurse didn¶t restate the question. Answer: (B) 2. Air can¶t be left in the space. rhonchi with bronchitis. Answer: (D) ³I should put on the stockings before getting out of bed in the morning. Rationale: Promote venous return by applying external pressure on veins. 3. According to Freudian theory. sometimes in massive amounts.05 mg/ 1 ml = . and bronchitis would have rhonchi. 93. There¶s a loss of lung parenchyma and subsequent scar tissue formation. the nurse can provide emotional support and further assess and validate the family¶s needs.

Rationale: This behavior is an example of reaction formation. Rationale: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Answer: (D) Exploring the meaning of the traumatic event with the client. Answer: (C) "Your problem is real but there is no physical basis for it. 19. 13. which will help her understand the underlying cause of her symptoms. have an onset of action of approximately 3 to 5 days. Answer: (C) Skeletal muscle paralysis. knowing that the cause is psychological wouldn't necessarily make her feel better. relieve physical symptoms of anxiety but don't relieve the anxiety itself. 16. Mood stabilizers aren't indicated because panic attacks are rarely associated with mood changes. Telling her that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict. The client must explore the meaning of the event and won't heal without this. Answer: (D) Increase calories. such as relaxation therapy. Antipsychotic drugs are inappropriate because clients who experience panic attacks aren't psychotic. an inability to concentrate. We'll work on what is going on in your life to find out why it's happened. Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. 17. carbohydrates. but tachycardia is frequently reported. A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem. symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. no matter how much time passes. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually.8. and protein. The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior. Behavioral techniques. The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence. 15. The therapeutic effects may continue for 1 to 2 weeks after discontinuation. Insomnia. a coping mechanism. Rationale: The nurse should designate times during which the client can focus on the compulsive behavior or obsessive thoughts. sleep medication is rarely appropriate. Otherwise. 14. Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia. Answer: (A) By designating times during which the client can focus on the behavior. 12. 11. . Answer: (A) A warning about the drugs delayed therapeutic effect. The client must be instructed to continue taking the drug as directed. NMS hasn't been reported with this drug. Answer: (A) Antidepressants Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Rationale: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. It is used to reduce the intensity of muscle contractions during the convulsive stage. and weight loss are common in depression. Why these drugs help control panic attacks isn't clearly understood. After the psychological conflict is resolved. The client will benefit from psychiatric treatment. 10. and elevated blood pressure. her symptoms will disappear. Answer: (B) Providing emotional support and individual counseling. Answer: (C) Acting overly solicitous toward the child." Rationale: The nurse must be honest with the client by telling her that the paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The other medications mentioned aren't effective in the treatment of OCD. Answer: (B) 3 to 5 days Rationale: Monoamine oxidase inhibitors. not rapidly. such as tranylcypromine. poor moto control. Anticholinergic agents. may help decrease the client's anxiety and induce sleep. Saying that it must be awful not to be able to move her legs wouldn't answer the client's question. Blood level checks aren't necessary. Answer: (B) Severe anxiety and fear. tachycardia. 9. Physical signs and symptoms of phobias include profuse sweating. Answer: (C) fluvoxamine (Luvox) and clomipramine (Anafranil) Rationale: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. which are smooth-muscle relaxants. Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. which is from 14 to 30 days. She shouldn't call attention to or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror in the client. 18. thereby reducing the risk of bone fractures or dislocation. A full clinical response may be delayed for 3 to 4 weeks. Rationale: This client increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates).

Withdrawal is a common response to stress. Logical thinking is the ability to think rationally and make responsible decisions. Neologisms are bizarre words that have meaning only to the client. tactile. and quit work without other plans for employment. and grandiose ideation. auditory. Answer: (D) A low tolerance for frustration Rationale: Clients with an antisocial personality disorder exhibit a low tolerance for frustration. hyperactivity. 21. Rationale: The nurse should listen to the client¶s requests. 27. sweating. Phencyclidine overdose can cause combativeness. Rationale: A delusion of grandeur is a false belief that one is highly important or famous. Answer: (D) Listening attentively with a neutral attitude and avoiding power struggles. rather than perceptions. and morphine. Repression is suppressing past events from the consciousness because of guilty association. Delusions are false beliefs. euphoria. Amphetamine overdose can result in agitation. 25. gustatory. characterized by apathy. and a lack of impulse control. and increased blood pressure. or olfactory perceptions that have no basis in reality. amphetamines. The nurse shouldn¶t be forced to stay seated at the table to finid=sh a meal. clear. Answer: (A) Highly important or famous. Answer: (C) Methadone Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn¶t have the same deterious effects as other opiates. miss work repeatedly. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. 26. 24. Aggressive behavior is uncommon. Answer: (B) Paranoid thoughts Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. The nurse should set limits in a calm. The client should be monitored during meals-not given privacy. They don't feel guilt about their behavior and commonly perceive themselves as victims. express willingness to seriously consider the request. heroin. Answer: (D) Denial Rationale: Denial is unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings. dilated pupils. such as cocaine. Answer: (B) Hallucinations Rationale: Hallucinations are visual. and impaired memory Rationale: Signs of antianxiety agent overdose include emotional lability. emotional immaturity. The other options are appropriate during the second stage of Alzheimer's disease. Answer: (C) Emotional lability. The family and friends should be included in the client¶s care. The nurse shouldn¶t try to restrain the client when he feels the need to move around as long as his activity isn¶t harmful. euphoria. Loose associations are rapid shifts among unrelated ideas. and benzodiazepines are highly addictive and would require detoxification treatment. During this stage. and impaired memory. impulses. 22. 20. A delusion of persecution is a false belief that one is being persecuted. Therefore. Barbiturates. regardless of the situation. if he can¶t remain seated long enough to eat a complete meal. They also display a lack of responsibility for the outcome of their actions. nursing care typically focuses on providing emotional support and individual counseling. Their behavior is emotionally cold with a flattened affect. They commonly have a history of unemployment. when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. and self-confident tone of voice. . Rationale: Establishing a consistent eating plan and monitoring the client¶s weight are very important in this disorder. that the client accepts as real. which would lead the client admitting the problem and seeking help. offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition. High calorie finger foods should be offered to supplement the client¶s diet. 28. or external facts that are consciously intolerable. although these clients may experience agitation with anxiety. Hallucinogen overdose can produce suspiciousness. These clients demonstrate a reduced capacity for close or dependent relationships. close relationships.Rationale: Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Exercise must be limited and supervised. and confusion. desires. and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. Answer: (C) Set up a strict eating plan for the client. Because of a lack of trust in others. clients with antisocial personality disorder commonly have difficulty developing stable. 23.

Answer: (D) Moderate-level anxiety Rationale: A moderately anxious person can ignore peripheral events and focuses on central concerns. which increase th heart rate and blood flow. as in option A. Answer: (C) Identify anxiety-causing situations Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. Answer: (B) Staying in the sun Rationale: Haldol causes photosensitivity. Answer: (D) A higher level of anxiety continuing for more than 3 months. Rationale: This is not an expected outcome of a crisis because by definition a crisis would be resolved in 6 weeks. 36. Answer: (B) Fine hand tremors or slurred speech Rationale: These are common side effects of lithium carbonate. Answer: (A) Client¶s perception of the presenting problem. Answer: (D) Encouraging the client to have blood levels checked as ordered. 31. 34. 42. cause a severe hypertensive response. Answer: (B) Chocolate milk. Answer: (C) Diverse interest Rationale: Before onset of depression. limited interest. . which affects the ability to register and recall recent events. but I believe you can hear them´. Options B and C are incorrect because amphetamines stimulate norepinephrine. Answer: (B) ³No. Answer: (A) Tension and irritability Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. Answer: (D) Males are more likely to use lethal methods than are females Rationale: This finding is supported by research. I do not hear your voices. when ingested in the presence of an MAO inhibitor. 33." Rationale: The nurse should set limits on client behavior to ensure a comfortable environment for all clients. 39. An overdose increases tension and irritability. such as option D. Answer: (C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes. 43. females account for 90% of suicide attempts but males are three times more successful because of methods used.29. 30. 38. Rationale: Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels. Rationale: Cell damage seems to interfere with registering input stimuli. 37. and yogurt¶´ Rationale: These high-tyramine foods. because it is the client¶s concept of the problem that serves as the starting point of the relationship. Answer: (B) 4 to 6 weeks Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks. 35. Rationale: The nurse can be most therapeutic by starting where the client is. Rationale: The nurse. vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure. as when the client gestures to hold the nurse¶s hand. 40. 44. aged cheese. 41. Answer: (D) Acceptance stage Rationale: Communication and intervention during this stage are mainly nonverbal. may decrease the client's self-esteem. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended. Diarrhea is a common adverse effect so option D in is incorrect. Answer: (A) As their depression begins to improve Rationale: At this point the client may have enough energy to plan and execute an attempt. Answer: (D) Presence Rationale: The constant presence of a nurse provides emotional support because the client knows that someone is attentive and available in case of an emergency. Option B is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. accepts the client¶s perceptions even though they are hallucinatory. Answer: (C) Confusion for a time after treatment Rationale: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. these clients usually have very narrow. demonstrating knowledge and understanding. 47. Answer: (D) Disturbance in recalling recent events related to cerebral hypoxia. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. 45. Judgmental remarks. 46. Severe sunburn can occur on exposure to the sun. 32.

Echinacea has immune-stimulating properties. the client is usually cooperative and exhibits socially appropriate behavior. Rationale: Dysthymic disorder is marked by feelings of depression lasting at least 2 years. or a minimum dose of 30 g. Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis. Lithium helps control the affective component of this disorder. the client can't perform selfcare activities and may become mute. similar to prescription antidepressants. Answer: (B) Sodium Rationale: Lithium is chemically similar to sodium.000/ l. generally is contraindicated in psychotic clients. Answer: (B) Impaired communication. and responses. Doses less than this will be ineffective. and back muscles. the medication must be stopped. During the early stage of this disease. even at the maximum dose. The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium. Because of the risk of agranulocytosis. another tricyclic antidepressant. mixed in 250 ml of water. Major depression is a recurring. Atypical affective disorder is characterized by manic signs and symptoms. 51. Dystonia is characterized by cramps and rigidity of the tongue. appetite disturbance. white blood cell (WBC) counts are necessary weekly. doses greater than this can increase the risk of adverse reactions. Hypotension may occur in clients taking this medication. a life-threatening reaction to neuroleptic medication that requires immediate treatment. Ginkgo biloba is prescribed to enhance mental acuity. 53. 56. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other antidepressant drugs such as imipramine. mouth. Answer: (B) Report a sore throat or fever to the physician immediately. 50. During the late stage. memory impairment may be the only cognitive deficit in a client with Alzheimer's disease. Rationale: Initially. difficulty making decisions. actions. John's wort has been found to have serotonin-elevating properties. the dosage may be reduced or the physician may prescribe nortriptyline. increasing the risk of toxicity. such as inappropriate conversation. is used to treat clients with cyclical schizoaffective disorder. and jitteriness. Akathisia causes restlessness. If the WBC count drops below 3. If sodium levels are reduced.48. Rationale: To minimize the effects of amitriptyline-induced orthostatic hypotension. is also used to treat clients with agoraphobia and that undergoing cocaine detoxification. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. Answer: (C) St. other than occasional irritable outbursts and lack of spontaneity. neck. 55. a psychotic disorder once classified under schizophrenia that causes affective symptoms. Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired communication. 52. The medication should be continued. an antianxiety agent. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. . Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases. Ephedra is a naturally occurring stimulant that is similar to ephedrine. face. Cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration marked by numerous periods of depression and hypomania. Answer: (D) It's characterized by an acute onset and lasts hours to a number of days Rationale: Delirium has an acute onset and typically can last from several hours to several days. 54. it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. an antimania drug. facial muscles. Answer: (D) Dysthymic disorder. John's wort Rationale: St. and hopelessness. primarily considered an antidepressant agent. a potentially lifethreatening complication of clozapine. These symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to a few weeks. Tardive dyskinesia causes involuntary movements of the tongue. with signs and symptoms recurring for at least 2 weeks. If the medication must be stopped. anxiety. Imipramine. Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome. Chlordiazepoxide. Answer: (C) lithium carbonate (Lithane) Rationale: Lithium carbonate. Answer: (C) 30 g mixed in 250 ml of water Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested. low energy or fatigue. persistent sadness or loss of interest or pleasure in almost all activities. and arm and leg muscles. even when symptoms have been controlled. lithium will be reabsorbed by the kidneys. 49. although toxicity doesn't occur with activated charcoal. 57. Orthostatic hypotension disappears only when the drug is discontinued. such as from sweating or diuresis. Answer: (B) Advising the client to sit up for 1 minute before getting out of bed. the nurse should advise the client to sit up for 1 minute before getting out of bed. including maniclike activity. subtle personality changes may also be present. low selfesteem. Answer: (C) Neuroleptic malignant syndrome. However. accompanied by at least two of the following symptoms: sleep disturbance. poor concentration. not monthly.

60. and confusion. monitoring the client's vital signs. Maintaining a consistent environment is therapeutic. Answer: (D) Rearrange the environment to activate the child Rationale: The child with autistic disorder does not want change. malnutrition. In intellectualization. . hallucinations. such as avoiding aged cheeses. and chicken livers. attention and the presence of papillary constriction. and D do not ensure that the client has controlled the behavior.Q. 68. With levels between 1. a CNS stimulant. cardiac dysrythmias. B. ataxia. Rationale: Tardive dyskinesia is a severe reaction associated with long term use of antipsychotic medication. of below 20. B. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. although rare. Intoxication with Marijuana. Ensure safety from self-destructive behaviors like head banging and hair pulling. as well as seizures. and face. Answer: (C) Blurred vision Rationale: At lithium levels of 2 to 2. and face. serum electrolyte level. A. diarrhea.5 and 2 mEq/L the client experiencing vomiting. and usually decreases as tolerance develops. such as this one. In reaction formation. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias. 63. Acceptance enhances a trusting relationship. 67. Answer: (A) Abnormal movements and involuntary movements of the mouth. peripheral vascular collapse. synesthesia and increase in vital signs D. Answer: (C) Moderate Rationale: The child with moderate mental retardation has an I. Answer: (D) This medication may initially cause tiredness. the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event. of 20-35. Answer: (A) Regression Rationale: An adult who throws temper tantrums. However. also. of 35. 62. if the client exhibits no signs of aggression after partial release of restraints.5 mEq/L the client will experienced blurred vision. dizziness. B. Answer: (D) Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. heart failure. social withdrawal.Q. the client acts in opposition to his feelings. serum electrolyte levels. and agitation. Therefore. Angry outburst can be re-channeling through safe activities. impaired judgment and hallucinations. D. which should become less bothersome over time. Antidepressants aren't habit forming and don't cause physical or psychological dependence. Symptoms of cocaine withdrawal include depression. Mild mental retardation 50-70 and Severe mental retardation has an I. and death. the dosage should be decreased gradually to avoid mild withdrawal symptoms. insomnia. conjunctival redness. yogurt. Answer: (B) cocaine Rationale: The manifestations indicate intoxication with cocaine. Options A. 64. and tachycardia. and acid-base balance. Rationale: Sedation is a common early adverse effect of imipramine. and acid base balance is crucial. muscle weakness. C. Answer: (C) Monitor vital signs. Side effects of Ritalin include anorexia. muscle twitching. a tricyclic antidepressant. include myocardial infarction. C. Rationale: The best indicator that the behavior is controlled. Intoxication with hallucinogen like LSD is manifested by grandiosity. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth.Q. Intoxication with heroine is manifested by euphoria then impairment in judgment. the client blames someone or something other than the source. are necessary for a client taking a monoamine oxidase inhibitor. 66. hypothermia. tongue. after a long course of high-dose therapy.58.5 to 3 mEq/L or higher. infection. Answer: (A) increased attention span and concentration Rationale: The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. 61. Alcohol withdrawal would show elevated vital signs. 59. Serious adverse effects. is displaying regressive behavior. In projection. C. the client may record food and fluid intake inaccurately. Option A may worsen anxiety. not a tricyclic antidepressant. 65. diarrhea and irritability.50 Profound Mental retardation has an I. or cardiac abnormalities secondary to electrolyte imbalances. There is no real withdrawal from cannibis. and persistent nausea and vomiting. Answer: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. urinary and fecal incontinence occurs. a cannabinoid is manifested by sensation of slowed time. A. slurred speech. Dietary restrictions. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem. tongue (fly catcher tongue). or behavior that is appropriate at a younger age. severe hypotension. At lithium levels of 2. anxiety.

Answer: (C) Hypochondriasis Rationale: Hypochodriasis in this case is shown by the client¶s belief that she has a serious illness. D. nausea. This is not congruent with therapeutic milieu. Answer: (B) Transference Rationale: Transference is a positive or negative feeling associated with a significant person in the client¶s past that are unconsciously assigned to another A. Xenophobia is fear of strangers. 80. polyuria and polydipsia. B. 77. safety. Answer: (C) Claustrophobia Rationale: Claustrophobia is fear of closed space. A. They are transitional or developmental periods in life 76. Conversion disorders are characterized by one or more neurologic symptoms. The client¶s symptoms don¶t suggest severe anxiety. 73. 71. Resistance is the client¶s refusal to submit himself to the care of the nurse 75. obesity and hypertension. Situational crisis is from an external source that upset ones psychological equilibrium C and D. Answer: (B) insidious onset Rationale: Dementia has a gradual onset and progressive deterioration. Answer: (B) Adventitious Rationale: Adventitious crisis is a crisis involving a traumatic event. Paroxetine is a scrotonin-specific reutake inhibitor used for treatment of depression panic . 70. B Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. A. The common side effects of Lithium are fine hand tremors. Answer: (C) A living. Answer: (B) Hypochondriasis Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with hypochondriasis. Axis III. 72. learning or working environment. Answer: (C) Major depression Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. Countert-transference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D.C and D are all characteristics of delirium. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. 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. Triangulation refers to conflicts involving three family members. although pathologic causes have been eliminated. B. limit setting. norms. B and C. The disturbance usually lasts at lease 6 with identifiable life stressor such as. C. Rationale: 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. Are the same. course examinations. A. The six environmental elements include structure. Intellectualization is a defense mechanism in which the client avoids dealing with emotions by focusing on facts. It causes pronounced memory and cognitive disturbances. the GI system is affected. Agoraphobia is fear of open space or being a situation where escape is difficult. A client experiencing sublimation channels maladaptive feelings or impulses into socially acceptable behavior 79. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. In many cases. Conversion disorder s are characterized by one or more neurologic symptoms. Borderline personality disorder as an Axis II. D. The manifestations are not due to drug interaction. 74. Splitting is a defense mechanism commonly seen in clients with personality disorder in which the world is perceived as all good or all bad. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. A. in this case. Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. A. These are therapeutic approaches. Answer: (A) Triazolam (Halcion) Rationale: Triazolam is one of a group of sedative hypnotic medication that can be used for a limited time because of the risk of dependence.69. It is not part of everyday life. Depersonalization refers to persistent recurrent episodes of feeling detached from one¶s self or body. D. 78. The next dose of lithium should be withheld and test is done to validate the observation. balance and unit modification. Answer: (B) Transference Rationale: Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the client¶s past to another person. Somatoform disorders generally have a chronic course with few remissions. Answer: (A) Revealing personal information to the client Rationale: Counter-transference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts.

Answer: (D) It promotes emotional support or attention for the client Rationale: Secondary gain refers to the benefits of the illness that allow the client to receive emotional support or attention. Personally change is common in Alzheimer¶s disease. 81. Primary gain enables the client to avoid some unpleasant activity. Answer: (D) The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. The inability to carry out motor activities is common in Alzheimer¶s disease. Loose associations don¶t necessarily start in a cogently. although some conflict is relieved. Teaching breathing control is a major intervention for clients with panic disorder. Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes. Flight of ideas is characterized by conversation that¶s disorganized from the onset. Flight of ideas is rapid shifting from one topic to another. Clients with histrionic personality disorder are dramatic. not suspicious and argumentative. 85. Answer: (A) ³I went to the mall with my friends last Saturday´ Rationale: Clients with panic disorder tent to be socially withdrawn. The duration of delirium is usually brief. Answer: (A) Vascular dementia has more abrupt onset Rationale: Vascular dementia differs from Alzheimer¶s disease in that it has a more abrupt onset and runs a highly variable course.disorder. Sufficient supporting data don¶t exist to suspect the other options as causes. nightmares. becoming quarrelsome and argumentative. Aphasia refers to a communication problem. or decrease sleeping difficulties. which is a false sensory perception. 89. Rationale: Minor memory problems are distinguished from dementia by their minor severity and their lack of significant interference with the client¶s social or occupational lifestyle. . Cyclothymic disorder is a mood disorder characterized by a mood range from moderate depression to hypomania. digoxin (a digitalis glycoxide). paranoid personalities ascribe malevolent activities to others and tent to be defensive. Somatoform pain disorder is a preoccupation with pain in the absence of physical disease. Answer: (A) ³I¶m sleeping better and don¶t have nightmares´ Rationale: MAO inhibitors are used to treat sleep problems. 91. Answer: (B) Behavioral difficulties Rationale: Adolescents tend to demonstrate severe irritability and behavioral problems rather than simply a depressed mood. 84. 88. Concrete thinking implies highly definitive thought processes. 86. 92. Hyperventilating is a key symptom of panic disorder. Clients with schizoid personality disorder are usually detached from other and tend to have eccentric behavior. Most clients with panic disorder with agoraphobia don¶t have nutritional problems. and intrusive daytime thoughts in individual with posttraumatic stress disorder. Clients with antisocial personality disorder can also be antagonistic and argumentative but are less suspicious than paranoid personalities. Answer: (D) Loose association Rationale: Loose associations are conversations that constantly shift in topic. Answer: (D) It¶s a mood disorder similar to major depression but of mild to moderate severity Rationale: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity. The client taking medications for panic disorder. and diazepam (a benzodiazepine). Answer: (C) Paranoid Rationale: Because of their suspiciousness. 90. Answer: (D) Stopping the drug can cause withdrawal symptoms Rationale: Stopping antianxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms. 87. 83. A dysfunctional family may disregard the real issue. Fluoxetine is a scrotonin-specific reuptake inhibitor used for depressive disorders and obsessive-compulsive disorders. furosemide (a thiazide diuretic). and obsessive-compulsive disorder. Risperidome is indicated for psychotic disorders. Seasonalaffective disorder is a form of depression occurring in the fall and winter. MAO inhibitors aren¶t used to help control flashbacks or phobias or to decrease the craving for alcohol. Stopping a benzodiazepine doesn¶t tend to cause depression. then becomes loose. Labile mood is more characteristic of a client with cognitive impairment or bipolar disorder. such as tricylic antidepressants and benzodiazepines. 82. Dysarthria is difficulty in speech production. Anxiety disorder is more commonly associated with small children rather than with adolescents. Answer: (D) The client is experiencing visual hallucination Rationale: The presence of a sensory stimulus correlates with the definition of a hallucination. Going to the mall is a sign of working on avoidance behaviors. increase cognitive abilities. Other options would be included in the history data but don¶t directly correlate with the client¶s lifestyle. Answer: (C) Drug intoxication Rationale: This client was taking several medications that have a propensity for producing delirium. must be weaned off these drugs. Cognitive impairment is typically associated with delirium or dementia.

and extrapyramidal adverse reactions aren¶t a problem. Disorganized speech is characterized by jumping from one topic to the next or using unrelated words. Answer: (A) ³I¶m not going to look just at the negative things about myself´ Rationale: As the clients makes progress on improving self-esteem. the client should be aware of adverse effects such as tardive dyskinesia.However.Answer: (A) Should report feelings of restlessness or agitation at once Rationale: Agitation and restlessness are adverse effect of haloperidol and can be treated with antocholinergic drugs. Answer: (C) Assess for possible physical problems such as rash Rationale: Clients with schizophrenia generally have poor visceral recognition because they live so fully in their fantasy world. have temper tantrums. Individuals with dependent personality disorders don¶t take over situations because they see themselves as inept and inadequate. Answer: (C) Hallucination Rationale: Hallucinations are sensory experiences that are misrepresentations of reality or have no basis in reality.93. They need to have as in-depth assessment of physical complaints that may spill over into their delusional symptoms. An idea of reference is a belief that an unrelated situation holds special meaning for the client. and seek attention. 96. Rationalization is a defense mechanism used to justify one¶s action. is the basic defense mechanism in schizophrenia. Talking with the client won¶t provide a assessment of his itching. and itching isn¶t as adverse reaction of antipsychotic drugs. these effects are due to a decreased in symptoms. Answer: (C) Explain that the drug is less affective if the client smokes Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. These clients focus on self and aren¶t envious or jealous. Ego-syntonicity refers to behaviors that correspond with the individual¶s sense of self. Ritualism behaviors are repetitive and compulsive. . 94. or experiences from awareness. it¶s an involuntary exclusion of painful thoughts. Clients with schizotypal personality disorder tend to be superstitious. Answer: (A) Lack of honesty Rationale: Clients with antisocial personality disorder tent to engage in acts of dishonesty. Olanzapine doesn¶t cause euphoria. not the drug itself. a return to earlier behavior to reduce anxiety. it¶s used primarily by people with paranoid schizophrenia and delusional disorder. 98. 97. Serotonin syndrome occurs with clients who take a combination of antidepressant medications. Delusions are beliefs not based in reality. feelings. shown by lying. Haloperidol isn¶t likely to cause photosensitivity or control essential hypertension. Projection is a defense mechanism in which one blames others and attempts to justify actions. Although the client may experience increased concentration and activity. Answer: (C) Regression Rationale: Regression. Answer: (B) Echopraxia Rationale: Echopraxia is the copying of another¶s behaviors and is the result of the loss of ego boundaries. Modeling is the conscious copying of someone¶s behaviors. Clients with dependent personality disorder tend to feel fragile and inadequate and would be extremely unlikely to discuss their level of competence and progress. selfblame and negative self evaluation will decrease. Clients with histrionic personality disorders tend to overreact to frustrations and disappointments. Repression is the basic defense mechanism in the neuroses. 100. 95. calling the physician to get the client¶s medication increased doesn¶t address his physical complaints. 99.

rather than sterile gloves. Turning on the patient¶s room ventilator c. A newly diagnosed diabetic patient 4. 30 seconds b. Vaginal instillation of conjugated estrogen b. Sterile technique is used whenever: a. Yawning b. hand washing should last at least: a. Nasogastric tube insertion d. Host b. to handle a sterile item b. Placing a sterile object on the edge of the sterile field d. A patient receiving broad-spectrum antibiotics c. A natural body defense that plays an active role in preventing infection is: a. Soap or detergent to promote emulsification b. Using sterile forceps. 1 minute c. 2 minute d. Opening the door of the patient¶s room leading into the hospital corridor d. Failing to wear gloves when administering a bed bath 3. Mode of transmission d. Which of the following will probably result in a break in sterile technique for respiratory isolation? a. Urinary catheterization 7.PART III PRACTICE TEST I FOUNDATION OF NURSING FOUNDATION OF NURSING 1. Hiccupping d. Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Terminal disinfection is performed c. All of the above 5. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container 9. Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? a. A postoperative patient who has undergone orthopedic surgery d. Opening the patient¶s window to the outside environment b. Colostomy irrigation 8. A patient with leukopenia b. Invasive procedures are performed d. Hot water to destroy bacteria c. After routine patient contact. 3 minutes 6. A disinfectant to increase surface tension d. Which of the following patients is at greater risk for contracting an infection? a. Effective hand washing requires the use of: a. Rapid eye movements . Which of the following procedures always requires surgical asepsis? a. Reservoir c. Body hair c. Touching the outside wrapper of sterilized material without sterile gloves c. Portal of entry 2. Protective isolation is necessary c. Strict isolation is required b.

Dysphagia 18. Presence of cardiac enzymes 16. Discard all used uncapped needles and syringes in an impenetrable protective container c. Potential for bleeding c. A signed consent is not required d. Inside of the gown 12. Eating. Potential for clot formation b. All of the following statement are true about donning sterile gloves except: a. Cap all used needles before removing them from their syringes b. and medications are allowed before this test .Which of the following blood tests should be performed before a blood transfusion? a. Hypokalemia b.All of the following measures are recommended to prevent pressure ulcers except: a. 15. 4. Complete blood count (CBC) and electrolyte levels. Blood typing and cross-matching c. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily.The primary purpose of a platelet count is to evaluate the: a. Cuffs of the gown d.500/mm3 b. the nurse should be careful that the first thing she touches is the: a. Before the procedure. The inside of the glove is considered sterile 11. Providing meticulous skin care 14. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. Using a water or air mattress c. metallic objects. a patient begins to exhibit fatigue.When removing a contaminated gown. c. Presence of an antigen-antibody response d.Which of the following statements about chest X-ray is false? a. Bleeding and clotting time d. and buttons above the waist c. Prothrombin and coagulation time b. b.Which of the following white blood cell (WBC) counts clearly indicates leukocytosis? a. Follow enteric precautions 13. Anorexia d.Which of the following nursing interventions is considered the most effective form or universal precautions? a. The first glove should be picked up by grasping the inside of the cuff. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist d.10. Massaging the reddened are with lotion b. drinking. Waist tie in front of the gown c. Adhering to a schedule for positioning and turning d. 25. 10. No contradictions exist for this test b.000/mm3 17. These symptoms probably indicate that the patient is experiencing: a.000/mm3 d. muscle cramping and muscle weakness.000/mm3 c. Wear gloves when administering IM injections d. Waist tie and neck tie at the back of the gown b. 7. the patient should remove all jewelry. Hyperkalemia c.

25G.6 mg b. IM injection or an IV solution b. 0. Can be used only when the patient is lying down d.Parenteral penicillin can be administered as an: a. 1 .The physician orders an IV solution of dextrose 5% in water at 100ml/hour. IV or an intradermal injection c.19. 25G d. What would the flow rate be if the drop factor is 15 gtt = 1 ml? a. and select the middle third on the anterior of the thigh 23. IM or a subcutaneous injection c. 22G 26. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds. Withhold the moderation and notify the physician b. Early in the morning b. 26G c.´ long d. 5 gtt/minute b.The appropriate needle size for insulin injection is: a. 10 mg c. Use a needle that¶s a least 1´ long c. 5/8´ long c. 13 gtt/minute c.A patient with no known allergies is to receive penicillin every 6 hours.M. Prepare the injection site with alcohol b.The appropriate needle gauge for intradermal injection is: a. Bruises too easily 24.The physician orders gr 10 of aspirin for a patient. Rub the site vigorously after the injection to promote absorption 22. After chest physiotherapy 20. The equivalent dose in milligrams is: a. injection is to: a. the nurse observes a fine rash on the patient¶s skin.The most appropriate time for the nurse to obtain a sputum specimen for culture is: a. When administering the medication.The correct method for determining the vastus lateralis site for I. Intradermal or subcutaneous injection d. After the patient eats a light breakfast c.The mid-deltoid injection site is seldom used for I. 60 mg d. 22G. Palpate a 1´ circular area anterior to the umbilicus d. injections because it: a.M. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm c. 20G b. The most appropriate nursing action would be to: a. 50 gtt/minute . Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest b. 600 mg 28. Administer the medication and notify the physician c. Can accommodate only 1 ml or less of medication b. 1 .´ long b. Administer the medication with an antihistamine d. Apply corn starch soaks to the rash 21. 25 gtt/minute d. 22G.All of the following nursing interventions are correct when using the Ztrack method of drug injection except: a. After aerosol therapy d. 1´ long 25. Does not readily parenteral medication 27. Aspirate for blood before injection d. 18G.

All of the following are appropriate nursing interventions except: a.Which of the following conditions may require fluid restriction? a. Chest pain c.Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? a. Renal Failure d.The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to: a. Tolerance b. The best nursing intervention is to: a. and pedal pulses every 15 minutes for 2 hours b. Distended neck veins 30.All of the following are common signs and symptoms of phlebitis except: a. Provide increased cool liquids c. Enteric-coated tablets that are thoroughly dissolved in water d. Provide increased ventilation . Edema and warmth at the IV insertion site c. Pain or discomfort at the IV insertion site b. Frank bleeding at the insertion site 32. Can be inhibited by ³splinting´ the abdomen 37.The nurse explains to a patient that a cough: a. Ask the patient to demonstrate the procedure 33. Is a protective response to clear the respiratory tract of irritants b. Allergy 35. popliteal. Check the pressure dressing for sanguineous drainage c. Most tablets designed for oral use. Capsules whole contents are dissolve in water c. Assess femoral. Urticaria d.An infected patient has chills and begins shivering. Assess a vital signs every 15 minutes for 2 hours d. Ask the patient if he/she has used ear drops before b. Any oral medications b.Which of the following types of medications can be administered via gastrostomy tube? a.29. except for extended-duration compounds 34. Idiosyncrasy c. Is primarily a voluntary action c. Apply iced alcohol sponges b. A red streak exiting the IV insertion site d. Provide additional bedclothes d. Fever b.A patient who develops hives after receiving an antibiotic is exhibiting drug: a. Dehydration 31. Chronic Obstructive Pulmonary Disease c. Hemoglobinuria b. Have the patient repeat the nurse¶s instructions using her own words c. Is induced by the administration of an antitussive drug d.A patient has returned to his room after femoral arteriography. Order a hemoglobin and hematocrit count 1 hour after the arteriography 36. Synergism d. Demonstrate the procedure to the patient and encourage to ask questions d.

Effective skin disinfection before a surgical procedure includes which of the following methods? a. Screen blood donors for antibodies to human immunodeficiency virus (HIV) b. Graduated from an associate degree program and is a registered professional nurse d. Aid in diagnosing a patient with AIDS d. Having the patient shower with an antiseptic soap on the evening v=before and the morning of surgery . An effect of medication d. Apricots d. Having the patient take a tub bath on the morning of surgery d.Clay colored stools indicate: a. Egg yolks c. Inhibit the growth of microorganisms 41. Bile obstruction c. Clamp the catheter for 1 hour every 4 hours to maintain the bladder¶s elasticity d. Maintain the drainage tubing and collection bag level with the patient¶s bladder b. 39.All of the following are good sources of vitamin A except: a. Decrease burning sensations b. Change the urine¶s color 40. Upper GI bleeding b. Change the urine¶s concentration d. Been certified by the National League for Nursing b. White potatoes b. Applying a topical antiseptic to the skin on the evening before surgery c.The purpose of increasing urine acidity through dietary means is to: a. Femoral and subclavian veins d. Irrigate the patient with 1% Neosporin solution three times a daily c. Received credentials from the Philippine Nurses¶ Association c.The two blood vessels most commonly used for TPN infusion are the: a. Completed a master¶s degree in the prescribed clinical area and is a registered professional nurse. Shaving the site on the day before surgery b. Brachial and subclavian veins c. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity 44. Analysis 42. Carrots c.Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place? a. Brachial and femoral veins 46. All of the above 45. Subclavian and jugular veins b. Impending constipation c. Assessmen t b.The ELISA test is used to: a.A clinical nurse specialist is a nurse who has: a. Planning d. Evaluation 43.38. In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain? a. Test blood to be used for transfusion for HIV antibodies c.

causing incontinence b. Abdominal muscles b. Increases partial thromboplastin time b. Kussmail¶s respirations and hypoventilation 50. ateclectasis.47.Immobility impairs bladder elimination. Cheyne-Strokes respirations and spontaneous pneumothorax d. bladder distention.Thrombophlebitis typically develops in patients with which of the following conditions? a. and hypostatic pneumonia b.In a recumbent. the nurse should use which muscles to avoid back injury? a. Leg muscles d. Upper arm muscles 48. Acute pulsus paradoxus c. lung ventilation can become altered. leading to such respiratory complications as: a. Urine retention. Back muscles c. immobilized patient. Diuresis. atypical pneumonia and respiratory alkalosis c. and decreased urine specific gravity d.When transferring a patient from a bed to a chair. Decreased calcium and phosphate levels in the urine . Chronic Obstructive Pulmonary Disease (COPD) 49. Respiratory acidosis. natriuresis. and infection c. An impaired or traumatized blood vessel wall d. Appneustic breathing. Increased urine acidity and relaxation of the perineal muscles. resulting in such disorders as a.

After routine patient contact. Enteric precautions prevent the transfer of pathogens via feces. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area.000/mm3 is associated with spontaneous bleeding. 9. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. hand washing may last from 10 seconds to 4 minutes. masks. requires that the door to the door patient¶s room remain closed. Leukopenia is a decreased number of leukocytes (white blood cells). 16. including surgery. the front is contaminated. A. so opening the window or turning on the ventricular is desirable. B. Strict isolation requires the use of clean gloves. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. slowly move backward away from the gown. Respiratory isolation. pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry. 13. In the operating room.M. The inside of the glove is always considered to be clean. hemolysis and antigen-antibody reactions will occur. and administration of parenteral therapy. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. 7. masks. Depending on the degree of exposure to pathogens. . In the circular chain of infection. The purpose of protective (reverse) isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. count of less than 20. however. discard it in a contaminated linen container. 11. taking broadspectrum antibiotics might actually reduce the infection risk. which are important in resisting infection.000/mm3 or less indicates a potential for bleeding. hand washing for 30 seconds effectively minimizes the risk of pathogen transmission. Normal WBC counts range from 5.000 to 100. D. hair covers. such as broken skin. and shoe covers for all invasive procedures. None of the other situations would put the patient at risk for contracting an infection. C. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. The back of the gown is considered clean. Rapid eye movement marks the stage of sleep during which dreaming occurs. 8. 15. All invasive procedures. 14.000/mm3. Thus. C. then wash her hands again. Before a blood transfusion is performed. instead they should be inserted in a specially designed puncture resistant. this is not its primary purpose. 2.000/mm3. A. catheter insertion. but not sterile. The nurse does not need to wear gloves for respiratory isolation. labeled container. A. the nurse should untie the back of the gown. 10. However. 3. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. However. traps and holds particles that contain microorganisms. 4. 5. and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. According to the Centers for Disease Control (CDC). Therefore. used needles should never be recapped. after removing gloves and washing hands. So. require sterile technique to maintain a sterile environment. Wearing gloves is not always necessary when administering an I. C. such as the nose. injection. like strict isolation. All equipment must be sterile. but good hand washing is important for all types of isolation. The edges of a sterile field are considered contaminated. gloves. blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. the patient¶s room should be well ventilated. D. the sterile items also become contaminated. a count of 25. research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. the nurse and physician are required to wear sterile gowns. The urinary system is normally free of microorganisms except at the urinary meatus. This is done by blood typing (a test that determines a person¶s blood type) and cross-matching (a procedure that determines the compatibility of the donor¶s and recipient¶s blood after the blood types has been matched).000 to 350. A.000/mm3 indicates leukocytosis. B. B. 6. When sterile items are allowed to come in contact with the edges of the field. holding the inside of the gown and keeping the edges off the floor. the blood of the donor and recipient must be checked for compatibility. Platelets are disk-shaped cells that are essential for blood coagulation. The normal count ranges from 150. 12. A.Nursing Crib ± Student Nurses¶ Community 200 ANSWERS AND RATIONALE ± FOUNDATION OF NURSING 1. Hair on or within body areas. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. Hot water may lead to skin irritation or burns. gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. A. turn and fold the gown inside out. D. A count of 100. It also is used to evaluate the patient¶s potential for bleeding. If the blood specimens are incompatible. B.

which is a potential side effect of diuretic therapy. a small-bore 25G needle is recommended. The patient can be in a supine or sitting position for an injection into this site. the inflammation of a vein. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. who may choose to substitute another drug. limiting the patient¶s intake of oral and I. D.M. D. Although applying corn starch to the rash may relieve discomfort. A.M. A. Fever. edema and heat at the I. 19.V. 22. Signs and symptoms of phlebitis include pain or discomfort. close to the brachial artery and radial nerve). 24. the abnormal presence of hemoglobin in the urine. insertion site. the patient can wear a lead apron to protect the pelvic region from radiation. An 18G. 25. The vastus lateralis. D. D. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication. It cannot be administered subcutaneously or intradermally. Because an intradermal injection does not penetrate deeply into the skin. or added to a solution and given I. and dehydration are conditions for which fluids should be encouraged. C. Because of this. drinking and medications are allowed because the X-ray is of the chest. Initial sensitivity to penicillin is commonly manifested by a skin rash. injections because it has relatively few major nerves and blood vessels. 1 . However. injections in children. a long. Hemoglobinuria. D. D.17. thick muscle that extends the full length of the thigh. 31. solutions or medications).´ needle is usually used for adult I. enteric-coated tablets. 18. and a 25G needle. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. 33. A 22G. for subcutaneous insulin injections. A 20G needle is usually used for I. Because of the danger of anaphylactic shock. it is not the nurse¶s top priority in such a potentially life-threatening situation. A 25G. muscle cramping. injections. A. A. fluids may be necessary. a 22G needle for I. Fatigue. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics.M. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm. and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level). metallic objects. Dysphagia means difficulty swallowing. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.V. 30. 32. and a red streak going up the arm or leg from the I. injections of oilbased medications.M.M. The nurse should seek an alternate physician¶s order when an ordered medication is inappropriate for delivery by tube. which are typically administered in the vastus lateralis or ventrogluteal site. Capsules. C. or a localized allergic reaction to the needle or catheter. D. In this reaction. Parenteral penicillin can be administered I. This procedure seals medication deep into the muscle. not the abdominal region. chronic obstructive pulmonary disease. 20. A. insertion site. the kidney loses their ability to effectively eliminate wastes and fluids. 5/8´ needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. thereby minimizing skin staining and irritation. if a chest X-ray is necessary. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. can be caused by chemical irritants (I. injection technique in which the patient¶s skin is pulled in such a way that the needle track is sealed off after the injection. is viewed by many clinicians as the site of choice for I. typically in the vastus lateralis. A. injections. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. 21. mechanical irritants (the needle or catheter used during venipuncture or cannulation). Phlebitis. Anorexia is another symptom of hypokalemia. even in individuals who have not been allergic to it previously.M. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 29. 1 . They are pharmaceutically manufactured in these forms for valid reasons. A signed consent is not required because a chest X-ray is not an invasive examination. gr 10 x 60mg/gr 1 = 600 mg 28. The middle third of the muscle is recommended as the injection site.V. Chest pain and urticaria may be symptoms of impending anaphylaxis. injections. 27.´ needle is usually used for I. Distended neck veins are an indication of hypervolemia. for I. and altering them destroys their purpose. 23. The Z-track method is an I. he nurse should withhold the drug and notify the physician. indicates a hemolytic reaction (incompatibility of the donor¶s and recipient¶s blood). Eating. and buttons would interfere with the X-ray and thus should not be worn above the waist. Jewelry.V. In real failure. D.M. A.M. antibodies in the recipient¶s plasma combine rapidly with donor RBC¶s. 26. Administering an antihistamine is a dependent nursing intervention that requires a written physician¶s order. the cells are hemolyzed in either circulatory or reticuloendothelial system. . and a 25G needle.V.

C. yielding light. not the day before. collectively predispose a patient to thromboplebitis. 35. however it can be voluntary. D. Many medications and foods will discolor stool ± for example. it appears to be genetically determined. D. This leads to bladder distention and urine stagnation. or other substance. Tachypnea (an abnormally rapid rate of breathing) would indicate that the patient was still hypoxic (deficient in oxygen). and upper arms may be easily injured. She must successfully complete the licensing examination to become a registered professional nurse. and injury to a blood vessel wall. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. 50. kidneys. Maintaing the drainage tubing and collection bag level with the patient¶s bladder could result in reflux of urine into the kidney. 44. clay-colored stool. commonly the result of anticoagulant (heparin) therapy. usually is involuntary. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. known as Virchow¶s triad. D. C. 47. 40. thereby increasing the risk of infection. is a drug interaction in which the sum of the drug¶s combined effects is greater than that of their separate effects. broccoli. beets turn stool red. sweet potatoes. The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). atelectasis from reduced surfactant and accumulated mucus in the bronchioles. cream. 49. A clinical nurse specialist must have completed a master¶s degree in a clinical specialty and be a registered professional nurse. and cabbage) and yellow fruits (such as apricots. should be done immediately before surgery. which provide an excellent medium for bacterial growth leading to infection. squash. The reaction can range from a rash or hives to anaphylactic shock. collard greens. Bile colors the stool brown. 48. Shaving the site of the intended surgery might cause breaks in the skin. Attempts to cool the body result in further shivering. D. if indicated. a gradual decrease in urine production. 41. shivering results from the body¶s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS) 45. Animal sources include liver. B. Tub bathing might transfer organisms to another body site rather than rinse them away. as when a patient is taught to perform coughing exercises. In the evaluation step of the nursing process. butter. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase. 36. D. back. In an infected patient. Initial vasoconstriction may cause skin to feel cold to the touch. 38. impaired venous return to the heart. D.34. food. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin. Eupnea refers to normal respiration. . These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. Constipation is characterized by small. Splinting the abdomen supports the abdominal muscles when a patient coughs. increased metabloism. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. hard masses. D. 42. A.The partial pressures of arterial oxygen and carbon dioxide listed are within the normal range. A. Synergism. D. A. immobilize patient is at particular risk for respiratory acidosis from poor gas exchange. Because of restricted respiratory movement. The main sources of vitamin A are yellow and green vegetables (such as carrots. 39. drugs containing iron turn stool black. The factors. Muscles of the abdomen. however. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation. An antitussive drug inhibits coughing. she is prepared to provide bed side nursing with a high degree of knowledge and skill.. Upper GI bleeding results in black or tarry stool. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. Any inflammation or obstruction that impairs bile flow will affect the stool pigment. such as medical surgical nursing. A graduate of an associate degree program is not a clinical nurse specialist: however. and an increased specific gravity. Microorganisms usually do not grow in an acidic environment. and cantaloupe). a protective response that clears the respiratory tract of irritants. Idiosyncrasy is an individual¶s unique hypersensitivity to a drug. spinach. 46. Immobility also results in more alkaline urine with excessive amounts of calcium.. D. C. and egg yolks. A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing. Coughing. a recumbent. sodium and phosphate. 37. and thus increased heat production. blood hypercoagulability. and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions. D. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. shaving. 43.

³I had a son born at 38 weeks gestation. Reduce side effects d. November 7 d. Rhythm method 4. the nurse would use which of the following? a. Vasectomy 3. For the client who is using oral contraceptives. Diaphragm c. Maintain hormonal levels c. 10 pounds per trimester b. A total gain of 25 to 30 pounds 7. Daily enemas b. a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks. Female condom c. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections? a.PRACTICE TEST II Maternal and Child Health MATERNAL AND CHILD HEALTH 1. Oral contraceptives d. recommendations for which of the following contraceptive methods would be avoided? a. Postpartum client 5. the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following? a.´ the nurse should record her obstetrical history as which of the following? a. A client in her third trimester tells the nurse. Promiscuous young adult d. Decreased fluid intake 6. Decrease the incidence of nausea b. When taking an obstetrical history on a pregnant client who states. Doppler placed midline at the suprapubic region c. Stethoscope placed midline at the umbilicus b. Prevent drug interactions 2. Woman over age 35 b. Condoms d. ³I¶m constipated all the time!´ Which of the following should the nurse recommend? a. For which of the following clients would the nurse expect that an intrauterine device would not be recommended? a. External electronic fetal monitor placed at the umbilicus . December 27 8. September 27 b. Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? a. Fetoscope placed midway between the umbilicus and the xiphoid process d. Diaphragm b. 1 pound per week for 40 weeks c. G3 T2 P0 A0 L2 d. Nulliparous woman c. . the nurse determines her EDD to be which of the following? a. Laxatives c. Spermicides b. Using Nagele¶s rule. When teaching a client about contraception. When preparing to listen to the fetal heart rate at 12 weeks¶ gestation. G2 T2 P0 A0 L2 b. October 21 c. When preparing a woman who is 2 days postpartum for discharge. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. pound per week for 40 weeks d. G4 T1 P1 A1 L2 9. Increased fiber intake d. G3 T1 P1 A0 L2 c.

Which of the following should the nurse do first? a.Before assessing the postpartum client¶s uterus for firmness and position in relation to the umbilicus and midline. Speculum examination reveals 2 to 3 cms cervical dilation. Ambulate her in the hall d. thready.10. Dietary intake 12. Depression c. 4 hours¶ postpartum that are as follows: BP 90/60. Recheck the blood pressure with another cuff c. Which of the following would be the priority when assessing the client? a. Determine the amount of lochia 17. Encourage her to wear a nursing brassiere d.Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? a. Hand/face edema d. Assess the vital signs b. Imminent abortion c.The nurse assesses the vital signs of a client. A dark red discharge on a 2-day postpartum client b. pulse 100 weak. Risk for infection b. A bright red discharge 5 days after delivery .When developing a plan of care for a client newly diagnosed with gestational diabetes. Glucose monitoring 11. Administer analgesia c. R 20 per minute. temperature 100. Exercise d.Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples? a. Report the temperature to the physician b. Use soap and water to clean the nipples 16. Pain c. which of the following should the nurse do first? a. A pink to brownish discharge on a client who is 5 days postpartum c. Missed abortion 13. Dietary intake b.The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Almost colorless to creamy discharge on a client 2 weeks after delivery d. Assist her to urinate 15.A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Anticipatory Grieving 14. Knowledge Deficit d. Tell her to breast feed more frequently b. Assess the uterus for firmness and position d. Complete abortion d. Glucosuria b. Which of the following assessments would warrant notification of the physician? a. Threatened abortion b. Medication c. The nurse would document these findings as which of the following? a.4oF. which of the following instructions would be the priority? a.A client 12 weeks¶ pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Administer a narcotic before breast feeding c.

The mother asks the nurse. Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn? a. and not descending as normally expected. Placing crib close to nursery window for family viewing d. nostril flaring. Teaching about the importance of family planning 20. Which of the following statements by the mother indicates effective teaching? a. µAlcohol helps it dry and kills germs´ c. Increased intracranial pressure 22. mild intercostals retractions. ³The breast tissue is inflamed from the trauma experienced with birth´ b. Incision d. ³An antibiotic ointment applied daily prevents infection´ d. Placing infant under radiant warmer after bathing b.4oF. Hemorrhage c.Immediately after birth the nurse notes the following on a male newborn: respirations 78. ³A decrease in material hormones present before birth causes enlargement. assessing for which of the following is the priority? a. Discomfort d. ³What¶s wrong with my son¶s breasts? Why are they so enlarged?´ Whish of the following would be the best response by the nurse? a. Start oxygen per nasal cannula at 2 L/min. c. ³Daily soap and water cleansing is best´ b.´ c. Congenital hypothyroidism d. Breasts c. Call the assessment data to the physician¶s attention b. with a uterus that is tender when palpated. apical hearth rate 160 BPM. Talipes equinovarus b.A postpartum client has a temperature of 101. ³He can have a tub bath each day´ . Which of the following should the nurse assess next? a.18. Promoting comfort and restoration of health b. Covering the infant¶s head with a knit stockinette 21. Covering the scale with a warmed blanket prior to weighing c. Recognize this as normal first period of reactivity 25. Suction the infant¶s mouth and nares d. Dehydration 23. ³You should discuss this with your doctor.A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following? a. Urine 19. Fractured clavicle c. remains unusually large. Facilitating safe and effective self-and newborn care d.Which of the following is the priority focus of nursing practice with the current early postpartum discharge? a. It could be a malignancy´ d. Which of the following should the nurse do? a. Infection b. Exploring the emotional status of the family c.The nurse hears a mother telling a friend on the telephone about umbilical cord care.During the first 4 hours after a male circumcision. and grunting at the end of expiration. Lochia b. ³The tissue has hypertrophied while the baby was in the uterus´ 24.

From the fundus to the umbilicus 29. the hormonal stimulation of the embryo that must occur involves which of the following? a. ³When the discharge has stopped and the incision is healed. Secretion of estrogen by the fetal gonad . the nurse would select which of the following sites as appropriate for the injection? a. Daily weights b. proteinuria. Deltoid muscle b. Clitoris b.When preparing to administer the vitamin K injection to a neonate. and severe pitting edema. Bartholin¶s gland 33.26.´ d. Stress reduction 30. Respiratory problems b.To differentiate as a female.When measuring a client¶s fundal height. Seizure precautions c. ³After your 6 weeks examination. Anterior femoris muscle c.When performing a pelvic examination. ³When can we have sexual intercourse again?´ Which of the following would be the nurse¶s best response? a. Vastus lateralis muscle d. From the symphysis pubis to the xiphoid process c.´ c. Which of the following would be most important to include in the client¶s plan of care? a.A postpartum primipara asks the nurse. which of the following techniques denotes the correct method of measurement used by the nurse? a. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs? a. 4 ounces d. 2 ounces b. Parotid gland c. 6 ounces 27. the nurse observes a red swollen area on the right side of the vaginal orifice. Integumentary problems d. Elimination problems 28.The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? a. Gastrointestinal problems c. Right lateral positioning d.´ b. From the symphysis pubis to the fundus d.´ 31. Decrease in maternal androgen secretion c.A client with severe preeclampsia is admitted with of BP 160/110. Secretion of androgen by the fetal gonad d. From the xiphoid process to the umbilicus b. Increase in maternal estrogen secretion b. ³Anytime you both want to. 3 ounces c. Gluteus maximus muscle 32.A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. The nurse would document this as enlargement of which of the following? a. ³As soon as choose a contraceptive method. Skene¶s gland d.

Obtaining an order to begin IV oxytocin infusion b.A client at 8 weeks¶ gestation calls complaining of slight nausea in the morning hours. ³The placenta is covering most of your cervix. Facilitate relaxation.During a pelvic exam the nurse notes a purple-blue tinge of the cervix.Which of the following would be the nurse¶s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa? a. Eating six small meals a day instead of thee large meals 35. Avoiding the intake of liquids in the morning hours d.During a prenatal class. Braxton-Hicks sign b. the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following assessments should be avoided? a. Maternal vital sign b.A multigravida at 38 weeks¶ gestation is admitted with painless.´ c. Which of the following client interventions should the nurse question? a. bright red bleeding and mild contractions every 7 to 10 minutes. Preparing for a cesarean section for failure to progress d. McDonald¶s sign 37. Passive movement of the unengaged fetus c.The nurse understands that the fetal head is in which of the following positions with a face presentation? a. ³You will have to ask your physician when he returns. Eliminate pain and give the expectant parents something to do b. Administering a light sedative to allow the patient to rest for several hour c. Fetal kicking felt by the client d. Palpable contractions on the abdomen b.´ 41. The nurse understands that this indicates which of the following? a. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water b.´ b. Enlargement and softening of the uterus 36. Which of the following would the nurse anticipate doing? a.34.After 4 hours of active labor. Reduce the risk of fetal distress by increasing uteroplacental perfusion c. Partially extended d. ³You need a cesarean to prevent hemorrhage. Goodell¶s sign d. Increasing the encouragement to the patient when pushing begins 39. Contraction monitoring d. ³The placenta is covering the opening of the uterus and blocking your baby. Partially flexed . Chadwick¶s sign c. Completely flexed b.The nurse documents positive ballottement in the client¶s prenatal record. The nurse documents this as which of the following? a. Eating a few low-sodium crackers before getting out of bed c.´ d. the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? a. Cervical dilation 40. Completely extended c. possibly reducing the perception of pain d. Fetal heart rate c. Eliminate pain so that less analgesia and anesthesia are needed 38.

Above the maternal umbilicus and to the left of midline 43. Clinical nurse specialist d. Prepared childbirth 48. Symphysis pubis b.In the late 1950s. Which of the following was an outgrowth of this concept? a. delivery. Trophoblast 47. Chromosome b. Sharing of a common chorion 46. Prolapsed umbilical cord 45. In the lower-right maternal abdominal quadrant d. Meconium d. on which of the following would the nurse base the explanation? a. Nurse-midwifery c. Ischemic phase 50.A patient is in labor and has just been told she has a breech presentation. Secretory phase d. Menstrual phase b. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth? a. Zygote d. postpartum (LDRP) b. Quickening b. Leuteinizing hormone d. Ophthalmia neonatorum c. The nurse interprets this to be the result of which of the following? a. the nurse understands that the underlying mechanism is due to variations in which of the following phases? a. Pubic arch 49. Lanugo b.42. Gonadotropin releasing hormone . Each ova with the same genotype d. recovery. Above the maternal umbilicus and to the right of midline b. Testosterone c.When teaching a group of adolescents about male hormone production.A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager.With a fetus in the left-anterior breech presentation. Follicle-stimulating hormone b. Proliferative phase c. Hydramnio c. which of the following would the nurse include as being produced by the Leydig cells? a. Sacral promontory c. Ischial spines d.Which of the following refers to the single cell that reproduces itself after conception? a.When describing dizygotic twins to a couple. The nurse should be particularly alert for which of the following? a. consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Labor. Pica d. In the lower-left maternal abdominal quadrant c. Sharing of a common placenta c. Blastocyst c.When teaching a group of adolescents about variations in the length of the menstrual cycle. the nurse would expect the fetal heart rate would be most audible in which of the following areas? a. Two ova fertilized by separate sperm b.The amniotic fluid of a client has a greenish tint. Vernix 44.

2. or uterine abnormalities. However. Age is not a factor in determining the risks associated with IUD use. while birth form 20 weeks to 38 weeks is considered preterm (P). Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract. D. 4. C . During the first trimester. The pregnant woman should gain less weight in the first and second trimester than in the third. endometrial hyperplasia or carcinoma. 9 pounds by 30 weeks. because of the increased risk of sexually transmitted infections. C . not midway between the umbilicus and the xiphoid process. B . they do not provide reliable protection against the spread of sexually transmitted infections. Therefore. To obtain a date of September 27. To obtain the date of December 27. especially in women with more than one sexual partner. the uterus has not risen to the umbilicus at 12 weeks. 6. the diaphragm must be refitted. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. An IUD may increase the risk of pelvic inflammatory disease. when used correctly and consistently. avoidance of intercourse during this period. spermicidal jelly should be placed in the dome and around the rim. not 1 pound per week. To obtain the date of November 7. 8. At 12 weeks gestation. 7 days have been added to the last day of the LMP (rather than the first day of the LMP). Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. Most IUD users are over the age of 30. Although there is a slightly higher risk for infertility in women who have never been pregnant. but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation. The client has been pregnant four times. Birth at 38 weeks¶ gestation is considered full term (T). 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. A spontaneous abortion occurred at 8 weeks (A). At 12 weeks the FHR would be difficult to auscultate with a fetoscope. The fetal heart rate at this age is not audible with a stethoscope. pound per week would be 20 pounds for the total pregnancy. B. During the third trimester. postpartum infection. the IUD is an acceptable option as long as the risk-benefit ratio is discussed. the uterus rises out of the pelvis and is palpable above the symphysis pubis. . a total weight gain 25 to 30 pounds is recommended: 1. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity.5 pounds in the first 10 weeks. follicles do not mature.5 pounds by 40 weeks. A . D . for maximum effectiveness. The estrogen content of the oral site contraceptive may cause the nausea. She has two living children (L). and 27. In addition. Although the external electronic fetal monitor would project the FHR. plus 4 months (instead of 3 months) were counted back. 3. are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. the enlarging uterus places pressure on the intestines. Liquid in the diet helps provide a semisolid. especially intracellular organisms such as HIV. Although spermicides kill sperm. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). regardless of when the pill is taken. IUDs may be inserted immediately after delivery. spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks. For the couple who has determined the female¶s fertile period. As a result. thus decreasing the amount of water that is absorbed. 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January. and pregnancy is prevented. Male sterilization eliminates spermatozoa from the ejaculate. but this is not recommended because of the increased risk and rate of expulsion at this time. which could place the client at risk for infection transmission. is safe and effective. C . using the rhythm method. A weight gain of . less than the recommended amount. Use of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations. usually at the 6 weeks¶ examination following childbirth or after a weight loss of 15 lbs or more. changing the year appropriately. 9. An UID should not be used if the woman has an active or chronic pelvic infection. stool is softer and easier to pass. Condoms.5 pounds in the first 10 weeks. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. To calculate the EDD by Nagele¶s rule. including current pregnancy (G). the client should only gain 1. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation. 5. Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is taken. To ensure adequate fetal growth and development during the 40 weeks of a pregnancy. The diaphragm must be fitted individually to ensure effectiveness. soft consistency to the stool. ovulation is inhibited.ANSWERS AND RATIONALE ± MATERNAL AND CHILD HEALTH 1. 7. B . Use for more than 1 week can also lead to laxative dependency. Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. add 7 days to the first day of the last menstrual period and count back 3 months. Because of the changes to the reproductive structures during pregnancy and following delivery.

The standard of care recommends a fasting and 2. diet therapy is the mainstay of the treatment plan and should always be the priority. providing further evidence of a possible infection. Depression may cause either anorexia or excessive food intake. Thus. leukocytes and decidua. A . D. 16. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. when the lochia is typically pink to brownish.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes. Narcotics administered prior to breast feeding are passed through the breast milk to the infant. . Uterine assessment should not cause acute pain that requires administration of analgesia. However. erythrocytes. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. soften the breast. Dry nipple skin predisposes to cracks and fissures. cramping and vaginal bleeding are present. decidua. pain is the priority. but especially 5 days after delivery. leukocytes. dietary intake. frequency. the priority consideration at this time. usually unilateral. Before uterine assessment is performed. especially of the hands and face. not a breast problem. This is not. excessive intake would not be the primary consideration for this client at this time. Ambulating the client is an essential component of postpartum care. edema. or urgency. Thus. The data suggests an infection of the endometrial lining of the uterus. the nurse should check the amount of lochia present. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery. In a complete abortion all the products of conception are expelled. this is not the priority. should wear a supportive brassiere with wide cotton straps. fat. dark brown in appearance. Although rechecking the blood pressure may be a correct choice of action. However. 15. the nurse would document an imminent abortion. and uterine involution would not be affected. Temperatures up to 100. A missed abortion is early fetal intrauterine death without expulsion of the products of conception. The client data do not include dysuria. After 20 weeks¶ gestation. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms. The three classic signs of preeclampsia are hypertension. transient fever. cervical mucus. Although urine is checked for glucose at each clinic visit. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving. 13. but the nurse should check the extent of vaginal bleeding first. and microorganisms. Nipple soreness is not severe enough to warrant narcotic analgesia. epithelial cells. erythrocyes. prevent or reduce nipple soreness. is present for 2 to 3 days after delivery. The lochia may be decreased or copious. leading to excessive weight gain or loss. is the primary symptom. the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. All the client¶s data indicate a uterine problem. Although the potential for infection is always present. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. D. Lochia rubra. which may be caused by fluid retention manifested by edema. which may be a possible cause of the hemorrhage. This does not. All postpartum clients. Feeding more frequently. especially lactating mothers. Thus. A weak. A. not exercise. 18. but this is not the priority at this time. D. All pregnant women with diabetes should have periodic monitoring of serum glucose. and proteinuria. Exercise. which would necessitate assessing the client¶s urine. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage. symptoms of urinary tract infections. lower abdominal pain. usually 101oF. preeclampsia should be suspected. is important for all pregnant women and especially for diabetic women. those with gestational diabetes generally do not need daily glucose monitoring. and promote ease of correct latching-on for feeding. However. thus decreasing blood sugar. Any bright red vaginal discharge would be considered abnormal. B . containing epithelial cells. Although all of the choices are important in the management of diabetes. and foul smelling. may be present with breast engorgement. is the priority. will decrease the infant¶s frantic. but is not necessary prior to assessment of the uterus. 17. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. causing excessive sleepiness.10. Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. cholesterol crystals. a dark red discharge. however. when there is a rapid weight gain. it is not the first action that should be implemented in light of the other data. For the client with an ectopic pregnancy. In a threatened abortion. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua.hour postprandial blood sugar level every 2 weeks. because it burns up glucose. which can become sore and painful. C. 11. but there is no cervical dilation. 12. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. cervical mucus. however. A. Then it would be appropriate to check the uterus. B. thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. Typically. The data indicate a potential impending hemorrhage. it is essential that the woman empty her bladder. vigorous sucking from hunger and will decrease breast engorgement. about every 2 hours. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. 14. and bacteria. The symptoms may subside or progress to abortion. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important. Symptoms of mastitis include influenza-like manifestations.

causing mechanical obstruction or chemical pneumonitis. 21. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Because of edema. the nurse¶s priority is to facilitate the safe and effective care of the client and newborn. To determine the amount of formula needed. A knit cap prevents heat loss from the head a large head. signs will not appear within 4 hours after the surgical procedure. it is noninfectious (sterile) and nonirritating. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed. Culturally. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. Thus placing the newborn¶s crib close to the viewing window would be least effective. B . The feet are not involved with the Moro reflex. and promote diuresis. Newborns do not have breast malignancy. Thus. Although the infant has been given vitamin K to facilitate clotting. with the heel elevated. The data given reflect the normal changes during this time period. 25. C. but it is not a sign of increased intracranial pressure. C. and teaching about family planning are important in postpartum/newborn nursing care. they are not the priority focus in the limited time presented by early post-partum discharge. exploring the family¶s emotional status. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control. Based on the calculation. The postterm meconiumstained infant is not at additional risk for bowel or urinary problems. 28. Although feedings are withheld prior to the circumcision. The cord should be kept dry until it falls off and the stump has healed. B. Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction. 4 or 6 ounces are incorrect. The presence of excessive estrogen and progesterone in the maternalfetal blood followed by prompt withdrawal at birth precipitates breast engorgement. Choice of a contraceptive method is important. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion.weeks¶ examination has been used as the time frame for resuming sexual activity. 24. Even though the skin is stained with meconium. the physician does not need to be notified and oxygen is not needed. not as a prophylaxis. The primary discomfort of circumcision occurs during the surgical procedure. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Because of early postpartum discharge and limited time for teaching. 23. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald¶s measurement). and in plantar flexion. B. Although infection is a possibility. but seizure precautions are the priority. At birth some of the meconium fluid may be aspirated. In talipes equinovarus (clubfoot) the foot is turned medially. daily weight is important but not the priority. Heat loss by radiation occurs when the infant¶s crib is placed too near cold walls or windows. Hypothyroiddism has no effect on the primitive reflexes. A. 20. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. 30. which are signs of excessive secretions. . B . 27. 29. The trauma of the birth process does not cause inflammation of the newborn¶s breast tissue. Seizure precautions provide environmental safety should a seizure occur. 26. Antibiotic ointment should only be used to treat an infection.19. Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. but not the specific criteria for safe resumption of sexual activity. The nurse should use a nonelastic. the 6. Body heat is lost through evaporation during bathing. Suctioning is not necessary. B. Cessation of the lochial discharge signifies healing of the endometrium. The infant is not at increased risk for gastrointestinal problems. paper measuring tape. A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. do the following mathematical calculation. Hemorrhage is a potential risk following any surgical procedure. 22. 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. C . The client should be placed on her left side to maximize blood flow. This reply by the nurse would cause the mother to have undue anxiety. placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. but it may be resumed earlier. not afterward. C. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. a large body surface area of the newborn¶s body. Absence of the Moror reflex is the most significant single indicator of central nervous system status. 2. The infant¶s assessment data reflect normal adaptation. Breast tissue does not hypertrophy in the fetus or newborns. which will spontaneously resolve in 4 to 5 days after birth. B. the prophylactic dose is often not sufficient to prevent bleeding. The data do not indicate the presence of choking. reduce blood pressure. flexible. gagging or coughing. the chances of dehydration are minimal. Although promoting comfort and restoration of health. D .

which can cause complications. the fetal upper torso and back face the left upper maternal abdominal wall. 32. Breathing techniques can raise the pain threshold and reduce the perception of pain. 42. 39. The deltoid muscle of a newborn is not large enough for a newborn IM injection. 41. Enlargement and softening of the uterus is known as Piskacek¶s sign. the head is completely or partially flexed. Quickening is the woman¶s first perception of fetal movement. C . Administering light sedative would be done for hypertonic uterine contractions. because of the space between the presenting part and the cervix. 38. thus blocking the passageway for the baby. the gluteus maximus muscle should not be until the child has been walking 2 years. not breathing. A . Lanugo is the soft. 48. C . but they can reduce it. An increase in maternal estrogen secretion does not effect differentiation of the embryo. and maternal estrogen secretion occurs in every pregnancy. Roles for nurse midwives and clinical nurse specialists did not develop from this challenge. B . This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. The menstrual. cheesy substance covering the fetus. With a brow (forehead) presentation. With this presentation. 33. Positioning. not just most of it. With a face presentation. Bartholin¶s glands are the glands on either side of the vaginal orifice. D . the head is completely extended. Goodell¶s sign indicates softening of the cervix. D . Fetal kicking felt by the client represents quickening. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. The client¶s labor is hypotonic. C . prolapse of the umbilical cord is common. Secretion of androgen by the fetal gonad would produce a male fetus. the head would be partially extended. The clitoris is female erectile tissue found in the perineal area above the urethra. and pubic arch are not part of the mid-pelvis. The parotid glands are open into the mouth. C . Testosterone is produced by the Leyding cells in the seminiferous tubules. Injections into this muscle in a small child might cause damage to the radial nerve. the placenta is covering all the cervix. C. In a breech position. B . The greenish tint is due to the presence of meconium. 46. Monozygotic (identical) twins involve a common placenta. B . D . Telling the client to ask the physician is a poor response and would increase the patient¶s anxiety. A . Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. 45. 50. It is too early to anticipate client pushing with contractions. Fetal heart rate is important to assess fetal well-being and should be done. which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. The zygote is the single cell that reproduces itself after conception. Eating six small meals a day would keep the stomach full. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. Using bicarbonate would increase the amount of sodium ingested. They also promote relaxation. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. With a complete previa. Breathing techniques do not eliminate pain. 37. 36. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. Vernix is the white. sacral promontory. Eating low-sodium crackers would be appropriate. Prepared childbirth was the direct result of the 1950¶s challenging of the routine use of analgesic and anesthetics during childbirth. B . The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Because of the proximity of the sciatic nerve. 44. increases uteroplacental perfusion. Braxton Hicks contractions are painless contractions beginning around the 4th month. 47. same genotype. Although a cesarean would help to prevent hemorrhage. Preparing for cesarean section is unnecessary at this time. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. . D . Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. 35. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. which often decrease nausea. D . Ballottement is not a contraction. Flexibility of the uterus against the cervix is known as McDonald¶s sign. D . B . downy hair on the shoulders and back of the fetus. Monitoring the contractions will help evaluate the progress of labor. Ballottement indicates passive movement of the unengaged fetus. 49. 43. Chadwick¶s sign refers to the purple-blue tinge of the cervix. Assessing maternal vital signs can help determine maternal physiologic status. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. the statement does not explain why the hemorrhage could occur. 34. The chromosome is the material that makes up the cell and is gained from each parent. The symphysis pubis. Pica refers to the oral intake of nonfood substances. D . Blastocyst and trophoblast are later terms for the embryo after zygote. A . The other positions would be incorrect. The nurse should call the physical and obtain an order for an infusion of oxytocin. Hydramnios represents excessive amniotic fluid. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. Skene¶s glands open into the posterior wall of the female urinary meatus. The hypothalamus is responsible for releasing gonadotropin-releasing hormone. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. With a vertex presentation. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. A complete placenta previa occurs when the placenta covers the opening of the uterus. 40. and common chorion.31. secretory and ischemic phases do not contribute to this variation.

b. Apple juice c. Assess the pain further c. After 24 hrs of surgery. Elevate the scrotum using a soft support d. A client is admitted to the hospital with benign prostatic hyperplasia. Which among the following complications should the nurse anticipates: a. The nurse should: a. Hypotension d. A history of high risk sexual behaviors.MEDICAL SURGICAL NURSING 1. An elevated hematocrit level c. Raw carrots b. the female client complains of lumbar pain. Positive ELISA and western blot tests c. Prepare for a possible incision and drainage. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was: a. the nurse should expect the use of: a. Urethral discharge 7. Diuretics b. A client has undergone with penile implant. Liver disease b. Myocardial damage c. Aorta d. Distention of the lower abdomen c. Halfway through the administration of blood. Right atrium b. Marco who was diagnosed with brain tumor was scheduled for craniotomy. 3. Cottage cheese 5. Increase the flow of normal saline b. Hypertension d. the nurse most relevant assessment would be: a. Hypokalemia 6. Whole wheat bread d. Assist the client with sitz bath b. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Steroids d. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. 8. After stopping the infusion Nurse Hazel should: a. Flank pain radiating in the groin b. Evidence of extreme weight loss and high fever 4. Anticonvulsants 2. Superior vena cava c. Obtain vital signs. Cancer 9. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following: a. Notify the blood bank d. An increased myoglobin level suggests which of the following? a. Antihypertensive c. Flapping hand tremors b. In preventing the development of cerebral edema after surgery. Identification of an associated opportunistic infection d. Pulmonary . Perineal edema d. Apply war soaks in the scrotum c. the client¶s scrotum was edematous and painful.

gastric distension 19. Replacing depleted blood products . Before the clients goes to surgery. 60 60 70 years 18. meningeal irritation d. chemotherapy side effects c. Intake and out put 16. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12? a. Bowel function b. Pain 11. Peripheral sensation c. Karen has been diagnosed with aplastic anemia. Broccoli 15. The nurse priority nursing diagnosis would be: a. name band d. High levels of high density lipid (HDL) cholesterol c. 40 to 50 years d. Low concentration triglycerides d. Low levels of LDL cholesterol.10. Which of the following is contraindicated with the client? a. Bleeding tendencies d. Treating the underlying cause d. The following are lipid abnormalities. High levels of low density lipid (LDL) cholesterol b. 4 to 12 years. effects of radiation b. The nurse monitors for changes in which of the following physiologic functions? a. Administering Coumadin c. Lydia is scheduled for elective splenectomy. Which of the following is a risk factor for the development of atherosclerosis and PVD? a. Potential wound infection b. 13. Potential ineffective coping c. empty bladder 17. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm? a. Grains d. Deficient fluid volume d. vegetables c. signed consent b. Impaired skin integrity c. 20 to 30 years c. vital signs c. These clinical manifestations may indicate all of the following except a. the nurse in charge final assessment would be: a. high blood pressure b. Potential electrolyte balance d. shortness of breath 12. Marie with acute lymphocytic leukemia suffers from nausea and headache. dairy products b. headache d. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including: a. Ineffective health maintenance b. stomach cramps c. Potential alteration in renal perfusion 14. Administering Heparin b. A client has been diagnosed with hypertension. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)? a. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). b.

Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. Report any discomfort or stiffness to the physician d. Cleanse the leg by scrubbing with a brisk motion b. Weighing daily c. Axillary regions d. A female client is receiving IV Mannitol. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer? a. Prolonged reperfusion of the toes after blanching d. Swelling of the left thigh b. A male client¶s left tibia is fractures in an automobile accident. An assessment specific to safe administration of the said drug is: a. Airway obstruction c. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the: a. Promotes the removal of antibodies that impair the transmission of impulses b. Dysphagia 22. To assess for damage to major blood vessels from the fracture tibia. Ears c. Increased skin temperature of the foot 26. Palms of the hand c. 27. which are set apart . d. Increased blood pressure 28. Use of smaller gauge needle. the nurse in charge should monitor the client for: a. Urine output hourly d. Face d. Level of consciousness q4h 24. Systolic blood pressure greater than 110 mmhg 21. Put leg through full range of motion twice daily c. Abdomen c. the male client should: a. Stimulates the production of acetylcholine at the neuromuscular junction. Lower cost with reusable insulin cartridges d. and a cast is applied. Shorter injection time c. The nurse explains that the advantages of these devices over syringes includes: a. NurseVivian should assess for additional tophi (urate deposits) on the: a. Elevate the leg when sitting for long periods of time. Urine output greater than 30ml/hr b. The nurse understands that this therapy is effective because it: a. 25. Feet. Hoarseness d. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. c. Vital signs q4h b. While performing a physical assessment of a male client with gout of the great toe. Diastolic blood pressure greater than 90 mmhg d. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate? a. Buttocks b.20. Decreases the production of autoantibodies that attack the acetylcholine receptors. Palms of the hands and axillary regions b. Respiratory rate of 21 breaths/minute c. 23. After a long leg cast is removed. Inhibits the breakdown of acetylcholine at the neuromuscular junction. Stomatitis b. Accurate dose delivery b.

Flexion exercises three times daily 30. The nurse is aware the early indicator of hypoxia in the unconscious client is: a. ³the only time I am without pain is when I lie in bed perfectly still´. Which of the following instruction is most appropriate? a. ³What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years? a. Pupil size and papillary response b. and avoid fatigue. Hypovolemia b. Restlessness 37. Marina with acute renal failure moves into the diuretic phase after one week of therapy. Active joint flexion and extension b. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. metabolic acidosis d. c. Uncontrolled . renal failure c. Range of motion exercises twice daily d. Mang Jose with rheumatoid arthritis states. Encourage client to drink plenty of fluids 31. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA? a. ³Practice using the mechanical aids that you will need when future disabilities arise´. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Cyanosis b. During the convalescent stage. Echocardiogram d. A male client has undergone spinal surgery. Head trauma c. b. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)? a.29. d. Spastic d. Continued immobility until pain subsides c. Nurse Myrna should expect the function of the bladder to be which of the following? a. hyperkalemia 32. ³You will need to accept the necessity for a quiet and inactive lifestyle´. ³Keep active. A 22 year old client suffered from his first tonic-clonic seizure. Electrolyte imbalance b. Increased respirations c. 36. Protein b. Congenital defect 34. use stress reduction strategies. Hypertension d. Assess the client¶s feet for sensation and circulation d. Epilepsy d. Atonic c. Specific gravity c. the nurse in charge with Mang Jose should encourage: a. During this phase the client must be assessed for signs of developing: a. A client is experiencing spinal shock. Microorganism 33. Observe the client¶s bowel movement and voiding patterns b. the nurse should: a. Bowel sounds 35. ³Follow good health habits to change the course of the disease´. Upon awakening the client asks the nurse. cholesterol level c. Glucose d. Normal b. Log-roll the client to prone position c.

Increased blood pressure d. Headache b. elder abuse . Daily baths with fragrant soap c. Increased cardiac output b.38. Total volume of circulating whole blood b. Acute respiratory distress syndrome (ARDS) c. Antihistamines d. Causing factors d. A client with bowel obstruction c. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere's disease except: a. Damage to laryngeal nerves 46. Bladder distension c. Progression stage b. Which of the client¶s action could aggravate the cause of flare ups? a. The bruises are probably caused by: a. Ability to move legs 44. Intensity 40. Permeability of kidney tubules 47.T. A 65 year old female is experiencing flare up of pruritus. Total volume of intravascular plasma c. which is the most significant? a. 49-year-old client c. Among the following clients. increased blood supply to the skin c. Initiation stage c. Among the following components thorough pain assessment. Nurse Jon assesses vital signs on a client undergone epidural anesthesia.I 42. Effect b. increased capillary fragility and permeability b. Antiemetics b. An 83-year-old woman has several ecchymotic areas on her right arm. Using clothes made from 100% cotton d. Diuretics c. Permeability of capillary walls d. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the: a. 67-year-old client b. Dizziness d. 15-year-old client 43. 33-year-old client d. Which of the following would the nurse assess next? a. Cause c. A client with high blood b. Glucocorticoids 45. which among them is high risk for potential hazards from the surgical experience? a. A client with U. Sleeping in cool and humidified environment b. Which of the following complications associated with tracheostomy tube? a. A client with glaucoma d. Regression stage d. Increasing fluid intake 41. Which of the following stage the carcinogen is irreversible? a. Atropine sulfate (Atropine) is contraindicated in all but one of the following client? a. self inflicted injury d. Promotion stage 39.

48. Monitor for signs of infection c. A client has undergone laryngectomy. The immediate nursing priority would be: a. Promote means of communication . 3 years and more 50. Nausea and vomiting b. 3 to 5 months d. Nurse Brian¶s accurate reply would be: a. flank pain c. 1 to 3 weeks b. 6 to 12 months c. weight gain d. Keep trachea free of secretions b. Provide emotional support d. intermittent hematuria 49. Nurse Anna is aware that early adaptation of client with renal carcinoma is: a. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued.

It is the asymptomatic nature of hypertension that makes it so difficult to treat. 5.A. A . Urine output provides the most sensitive indication of the client¶s response to therapy for hypovolemic shock. 26. and then normal saline should be infused to keep the line patent and maintain blood volume. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. 9. 27. 3. nitroglycerin often produces side effects such as headache. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. therefore palpable. 22. 8. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney. There is a potential alteration in renal perfusion manifested by decreased urine output. white blood cells. 28. D . C . Early warning signs of laryngeal cancer can vary depending on tumor location. 13. A . 11. One cup of cottage cheese contains approximately 225 calories. B . The blood must be stopped at once. When mitral stenosis is present. Clients with hypertension frequently do not experience pain. Uric acid has a low solubility. 20. Aplastic anemia decreases the bone marrow production of RBC¶s. or impaired skin integrity. 24. and 6 g of carbohydrate. 4. Because of its widespread vasodilating effects. or prolonged aortic cross-clamping during the surgery. B . 18. B . C . C . . 16. D . B . 14. Good source of vitamin B12 are dairy products and meats. Steroids decrease the body¶s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction 23. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV). the pulmonary circulation is under pressure. 7. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life. 12. 15. 25. 10. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels. B . The palms should bear the client¶s weight to avoid damage to the nerves in the axilla. which decreases the development of edema. including cartilaginous tissue such as the ears. hypotension and dizziness. A . D . 2. C . 9 g of fat. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs. C . It is uncommon after 15 years of age. A . 21. C . The client is at risk for bruising and bleeding tendencies. B . C . resulting in flapping hand tremors. reducing edema and pain. Damage to blood vessels may decrease the circulatory perfusion of the toes. A . These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.Nursing Crib ± Student Nurses¶ Community 231 ANSWERS AND RATIONALE ± MEDICAL SURGICAL NURSING 1. It does invade the central nervous system. this would indicate the lack of blood supply to the extremity. the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein. A . 27 g of protein. D . Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin. D . prolonged hypotension. deficient volume. 19. Elevation of uremic waste products causes irritation of the nerves. it tends to precipitate and form deposits at various sites where blood flow is least active. 6. Urine output should be consistently greater than 30 to 35 mL/hr. A . 30 mg cholesterol. and clients experience headaches and vomiting from meningeal irritation. Elevation increases lymphatic drainage. B . The altered renal perfusion may be related to renal artery embolism. Elevation will help control the edema that usually occurs. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. 17. and platelets. This indicates that the bladder is distended with urine. C . Managing hypertension is the priority for the client with hypertension. Glucocorticoids (steroids) are used for their anti-inflammatory action.

A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system. 48. and vascular disease. Intermittent pain is the classic sign of renal carcinoma. therefore removal of secretions is necessary. 49. A . the capillaries and small vessels dilate. C . The nurse should suspect hypoxia in unconscious client who suddenly becomes restless. C . and cell damage cause the release of a histamine-like substance. and the nurse in charge should monitor the client for distended bladder. 34. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. 45. 39. A . D . In burn. . 41. use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active. Glucocorticoids play no significant role in disease treatment. withdrawal from drugs and alcohol. 31. The use of fragrant soap is very drying to skin hence causing the pruritus. alternating extension. Aging process involves increased capillary fragility and permeability. A . and adduction. B . the bladder becomes completely atonic and will continue to fill unless the client is catheterized. hypovolemia may occur and fluids should be replaced. 35. 33. B . The nurse most positive approach is to encourage the client with multiple sclerosis to stay active.29. 37. 46. 47. Other common causes of seizure activity in adults include neoplasms. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment. D . C . The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost. 36. 42. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis. 38. 40. It is primarily due to capillary erosion by the cancerous growth. Trauma is one of the primary cause of brain damage and seizure activity in adults. A . D . if these occurs notify physician immediately. Active exercises. 43. infection and laryngeal nerve damage. B . C . The constituents of CSF are similar to those of blood plasma. flexion. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure. mobilize exudates in the joints relieves stiffness and pain. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed. A . Tracheostomy tube has several potential complications including bleeding. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves. 32. Patent airway is the most priority. A CSF normally contains glucose. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion. 30. Restlessness is an early indicator of hypoxia. B . abduction. D . The last area to return sensation is in the perineal area. In spinal shock. Alteration in sensation and circulation indicates damage to the spinal cord. A . C . A . B . 50. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily. 44. D .

The most appropriate nursing intervention should include? a. Avoiding relationship c. Observe her 4. Nurse Monet is caring for a female client who has suicidal tendency.A. Turning on the television b.) c. Connected to client unrelated to oneself 7. This perception is known as: a. Aversion Therapy 2. Restrict visits with the family 5. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. A female client is admitted with a diagnosis of delusions of GRANDEUR. Alcoholics anonymous (A. Showing interest in solitary activities d. Responsible for evil world d. Staying with the client and speaking in short sentences d. This diagnosis reflects a belief that one is: a. A 20 year old client was diagnosed with dependent personality disorder. Emotional affect c. Which behavior is not likely to be evidence of ineffective individual coping? a. Hallucinations b. A client is experiencing anxiety attack. Delusions c. Inability to make choices and decision without advise 8. Nurse Monet should« a. Aggressive behavior . Ask the client to play with other clients 6. Recurrent self-destructive behavior b. Paranoid thoughts b. Allow her to urinate c. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Leaving the client alone c. Encourage client to exercise to reduce anxiety d. Which action should the nurse include in the plan? a. Nurse Trish should tell the client that the only effective treatment for alcoholism is: a. Highly famous and important c.PSYCHIATRIC NURSING 1. Total abstinence d. Open the window and allow her to get some fresh air d. Provide privacy during meals b. A male client is diagnosed with schizotypal personality disorder. Give her privacy b. Which signs would this client exhibit during social situation? a. Set-up a strict eating plan for the client c. Psychotherapy b. When accompanying the client to the restroom. Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. Loose associations d. Being Killed b. Independence need d. Neologisms 3.

limiting unnecessary interaction c. Which of the following interventions would be most appropriate? a. Feeling of unworthiness and hopelessness 17. Apathetic response to the environment b. Involve client in planning daily meal c.C. Feelings of guilt and inadequacy d.9.A neuromuscular blocking agent is administered to a client before ECT therapy. Generates new levels of awareness b. Teach client to measure I & O b. Has maximum ability to solve problems and learn new skills d. Assumes responsibility for her actions c. ³I don¶t know´ answer to questions c. Increasing stimulation b. Nurse Trish recognizes that the basis of O. Problems with being too conscientious b.Mario is complaining to other clients about not being allowed by staff to keep food in his room. The symptom that is unrelated to depression would be? a. Allowing a snack to be kept in his room b. Nausea and vomiting c. Reprimanding the client c. Avoid shopping plenty of groceries 10. increasing appropriate sensory perception d. Which behavior by the client indicates adult cognitive development? a. Ignoring the clients behavior d. The Nurse should carefully observe the client for? a. ensuring constant client and staff contact 16. The most appropriate initial goal for a client diagnosed with bulimia is? a.A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Cardiac dysrhythmias resulting to cardiac arrest b. Dizziness d. Glucose intolerance resulting in protracted hypoglycemia c. Eat only three meals a day d. disorder is often: a. the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to? a.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer¶s type and depression. Decreased metabolism causing cold intolerance 15.Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be? a. Nurse Tony was caring for a 41 year old female client. Problems with anger and remorse c. Shallow of labile effect d. Setting limits on the behavior . Respiratory difficulties b. Observe client during meals d. Endocrine imbalance causing cold amenorrhea d. Neglect of personal hygiene 13.Nurse Trish is working in a mental health facility. Identify anxiety causing situations c. Her perception are based on reality 11.Nurse Anna can minimize agitation in a disturbed client by? a. Encourage to avoid foods b. Nurse Claire is caring for a client diagnosed with bulimia. Seizures 12. Monitor client continuously 14.

18.Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal? a. Soda d. Respect client¶s need for personal space 25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to: a.Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist? a. Which of the medications would the nurse expect to administer? a. Constipation & steatorrhea d. Consistency 21. Rationalization b. Naloxone (Narcan) b. Manipulate the environment to bring about positive changes in behavior b. Limit setting d. Benzlropine (Cogentin) c. Embarrassment c. Ignore the clients statement because it¶s a sign of manipulation 19. Ask a family member to stay with the client at home temporarily b. Allow the client¶s freedom to determine whether or not they will be involved in activities c. Discuss the meaning of the client¶s statement with her c. Give client feedback about behavior d.Joey a client with antisocial personality disorder belches loudly. Remorsefulness 20. Share an activity with the client c.Cely is experiencing alcohol withdrawal exhibits tremors. Vomiting and Diarrhea 24. Depensiveness b. diaphoresis and hyperactivity. Milk b. Use natural remedies rather than drugs to control behavior . Restlessness & Irritability c. Haloperidol (Haldol) 22. Role play life events to meet individual needs d. Orange Juice c. A staff member asks Joey. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Supportive confrontation c. Shame d.Conney with borderline personality disorder who is to be discharge soon threatens to ³do something´ to herself if discharged. Lorazepam (Ativan) d. Yawning & diaphoresis b. ³Do you know why people find you repulsive?´ this statement most likely would elicit which of the following client reaction? a. Encourage the staff to have frequent interaction with the client b. Request an immediate extension for the client d. Regular Coffee 23.To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety. the nurse in charge should? a. Which of the following actions by the nurse would be most important? a.Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal? a.

Avoidance of situation & certain activities that resemble the stress b. Ignore the client 32. Re-experiencing the trauma in dreams or flashback 33.A 60 year old female client who lives alone tells the nurse at the community health center ³I really don¶t need anyone to talk to´. The TV is my best friend. Displacement b. The duty nurse approaches in an attempt to alleviate Linda¶s anxiety.Nurse Perry is aware that language development in autistic child resembles: a. Have more positive relation with the father than the mother b. Concretism . Have been physically abuse 27. Would you like me to talk with you? c. Echolalia 29. Depression and a blunted affect when discussing the traumatic situation c. Lack of interest in family & others d. Does not respond to conventional treatment c.Linda is pacing the floor and appears extremely anxious. Looks almost identical to adult depression 28. Would you like to watch TV? b. Distortion of reality when completing daily routines 31. The nurse recognizes that the client is using the defense mechanism known as? a. Associative looseness c. Be able to develop only superficial relation with the others d. the client cannot remember facts and fills in the gaps with imaginary information. Denial 30.When working with a male client suffering phobia about black cats.Nurse Benjie is communicating with a male client with substance-induced persisting dementia. Shuttering d. The most therapeutic question by the nurse would be? a. Scanning speech b.When teaching parents about childhood depression Nurse Trina should say? a. Speech lag c.26. It may appear acting out behavior b. Are you feeling upset now? d. Is short in duration & resolves easily d. Confabulation d. Projection c. Nurse Trish should anticipate that a problem for this client would be? a. Sublimation d.Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to: a. Flight of ideas b. Nurse Benjie is aware that this is typical of? a. Anger toward the feared object c. Denying that the phobia exist d. Anxiety when discussing phobia b.Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be: a. Cling to mother & cry on separation c.

March is little woman´. After detailed assessment. Minimal decision making d. Is used by the client primarily for secondary gains 40. 10% weight loss & alopecia c. its march. Concrete thinking c. Effective self boundaries d.A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop: a.A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be: a. Frequent regurgitation & re-swallowing of food b. Positive body image 36. Better self control c. Faith in his wife . Slow pulse. Engaging the client in conversing about current affairs d. Helps the client control the anxiety c.34. Previous history of gastritis c. Anger & resentment c. memory lapses & an increased pulse 35. Routine Activities c. is brought to the psychiatric hospital by his parents.Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are? a. Nurse Gina must recognize that the ritual: a.Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have: a. That¶s literal you know´. Helplessness & hopelessness 38.A nursing care plan for a male client with bipolar I disorder should include: a. Echolalia c. Is under the client¶s conscious control d.To further assess a client¶s suicidal potential. Helps the client focus on the inability to deal with reality b. a diagnosis of schizophrenia is made. Low self esteem b. Neologisms b.A 32 year old male graduate student. These statement illustrate: a. excessive fears & nausea d. Anxiety & loneliness d.A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse ³Yes. It is unlikely that the client will demonstrate: a. Providing a structured environment b. Feeling of self worth d. Excessive weight loss. Nurse Katrina should be especially alert to the client expression of: a. Touching the client provide assurance 39. Loosening of association 42. Excessive activity. Designing activities that will require the client to maintain contact with reality c. Multiple stimuli b. Varied Activities 37. Insight into his behavior b. who has become increasingly withdrawn and neglectful of his work and personal hygiene. Weak ego 41.When planning care for a female client using ritualistic behavior. Flight of ideas d. Compulsive behavior. Frustration & fear of death b. Badly stained teeth d. amenorrhea & abdominal distension b.

³You¶re having hallucination.Nurse Tina is caring for a client with delirium and states that ³look at the spiders on the wall´. b. Ask the client direct questions to encourage talking b. the client is found lying on the bed with a body pulled into a fetal position. The client maintains contact with a crisis counselor 49. Length of time on the med. but they are not going to hurt you´ c. 48. a. Grand mal seizure activity depresses respirations d.Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. Decrease oxygen to the brain increases confusion and disorientation c. The client identifies anxiety producing situations d. Verbalizing reasons that the client may not choose to eat 44. Neuroleptic medication b.Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. Psychosurgery d. Which goal would be most appropriately having been included in the plan of care requiring evaluation? a. Nurse Chris evaluates achievement of the discharge maintenance goals.Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The client eliminates all anxiety from daily situations b. The nurse anticipates that what treatment procedure may be prescribed. Reason for the suicide attempt d. ³I know you are frightened. The most important piece of information the nurse in charge should obtain initially is the: a. there are no spiders in this room at all´ b.Nurse Jonel is providing information to a community group about violence in the family. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because? a.A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit.During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation.When planning the discharge of a client with chronic anxiety. The client ignores feelings of anxiety c. Offering opinion about the need to eat d. ³Abuser usually have poor self-esteem´ 47. ³I can see the spiders on the wall.43. but I do not see spiders on the wall´ 46. Short term seclusion c. The nurse uses which communication technique to encourage the client to eat dinner? a. Focusing on self-disclosure of own food preference b. Name of the ingested medication & the amount ingested c. Leave the client alone and continue with providing care to the other clients 45. ³Abuse occurs more in low-income families´ b. Nurse Nina should? a. ³Would you like me to kill the spiders´ d. ³Abuser use fear and intimidation´ d. ³Abuser Are often jealous or self-centered´ c. When Nurse Nina enters the client¶s room. What should the nurse respond to the client? a. Anesthesia is administered during the procedure b. Which statement by a group member would indicate a need to provide additional information? a. Rake the client into the dayroom to be with other clients c. Name of the nearest relative & their phone number . Using open ended question and silence c. Sit beside the client in silence and occasionally ask open-ended question d. Muscle relaxations given to prevent injury during seizure activity depress respirations. Electroconvulsive therapy 50.

hoarding medications and talking about death. 4. B . Serving coffee top the client may add to tremors or wakefulness. there is little or no emotional involvement therefore little alteration in affect. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. C . Appropriate nursing interventions for an anxiety attack include using short sentences. gustatory. The nurse should discuss the client¶s statement with her to determine its meaning in terms of suicide. A . Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior. A . Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. With depression. Total abstinence is the only effective treatment for alcoholism 2. 14. these electrolytes are necessary for cardiac functioning. 5. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts 9. The Nurse should watch for clues. B . 8. Establishing a consistent eating plan and monitoring client¶s weight are important to this disorder. B . C . A . remaining calm and medicating as needed. D . An adult age 31 to 45 generates new level of awareness. D . A consistent approach by the staff is necessary to decrease manipulation. Delusion of grandeur is a false belief that one is highly famous and important. 11. C . D . A . When the staff member ask the client if he wonders why others find him repulsive. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. D . 18. 12. The Nurse has a responsibility to observe continuously the acutely suicidal client. 6. B . tactile or olfactory perceptions that have no basis in reality. therefore they must be carefully monitored. 7. such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles. The nurse needs to set limits in the client¶s manipulative behavior to help the client control dysfunctional behavior. Limiting unnecessary interaction will decrease stimulation and agitation. and messages. A . C . 19. Neuromuscular Blocker. 10. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them. auditory. such as communicating suicidal thoughts. The nurse would most likely administer benzodiazepine. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure. 15. B . Hallucinations are visual. 17. B . .ANSWERS AND RATIONALE ± PSYCHIATRIC NURSING 1. the client is likely to feel defensive because the question is belittling. 3. 22. decreasing stimuli. These clients often hide food or force vomiting. Any suicidal statement must be assessed by the nurse. The natural tendency is to counterattack the threat to self image. C . 16. A . 21. Nursing Crib ± Student Nurses¶ Community 243 20. staying with the client. D . 13. such as lorazepan (ativan) to the client who is experiencing symptom: The client¶s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

Electroconvulsive therapy is an effective treatment for depression that has . A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure. 26. A person with this disorder would not have adequate self-boundaries Nursing Crib ± Student Nurses¶ Community 244 41. 31. 44. A . The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action. 40. a defense that blocks problem by unconscious refusing to admit they exist 30. The nurse presence may provide the client with support & feeling of control. A simple daily routine is the best. such as temper tantrums. 36. A . acting out behavior. along with muscle spasm. Children have difficulty verbally expressing their feelings. C . The expression of these feeling may indicate that this client is unable to continue the struggle of life. fever. repetitive. D . The client statement is an example of the use of denial. may indicate underlying depression. 42. 49. The nurse facilitates communication with the client by sitting in silence. least stressful and least anxiety producing. D . A . Discussion of the feared object triggers an emotional response to the object. dependence. repeated interventions. 37. B . 45. 46. 34. Helping the client to develop feeling of self worth would reduce the client¶s need to use pathologic defenses. The autistic child repeat sounds or words spoken by others. Structure tends to decrease agitation and anxiety and to increase the client¶s feeling of security. Personal characteristics of abuser include low self-esteem. Vomiting and diarrhea are usually the late signs of heroin withdrawal. D . D . C . B . 39. Moving to a client¶s personal space increases the feeling of threat. 32. 29. 24. A . and require consistent. Clients who are withdrawn may be immobile and mute. Communication with withdrawn clients requires much patience from the nurse. C . 33. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits. D . D . 38. abdominal cramps and backache. Environmental (MILIEU) therapy aims at having everything in the client¶s surrounding area toward helping the client. insecurity and jealousy. B . C . Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. A . Dental enamel erosion occurs from repeated self-induced vomiting. Weight loss is excessive (15% of expected weight) 35. which increases anxiety. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. D . nausea. 28. D . These are the major signs of anorexia nervosa. 43. D . immaturity. A . asking open-ended question and pausing to provide opportunities for the client to respond. C . Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially 27. B . C . 48. C . Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder. 25. When hallucination is present. the nurse should reinforce reality with the client. 47. D . Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.23. Depression usually is both emotional & physical.

lives saving facts are obtained first. In an emergency. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.not responded to medication 50. . B .

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