PART I NURSING PRACTICE IFoundation of Professional NursingPractice 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 thatwould 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 inthe field. c.The statement in the drug literature about administration of terbutaline. d. The actions of a reasonably prudent nurse with similar educationand 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/μl. The female

client isdehydrated and receiving dextrose 5% in half-normal saline solution at150 ml/hr. The client complains of severe bone pain and is scheduled toreceive a dose of morphine sulfate. In administering the medication, NurseTrish should avoid which route? A d . . I S V C b I M c . O r a l

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.

intravenous(IV) has infiltrated.d.A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated withserosanguinous fluid.6.Nurse Gail places a client in a fourpoint restraint following orders from thephysician. 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.

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

5.Nurse Betty is assigned to the following clients. The client that the nursewould see first after endorsement?a.A 34 year-old post operative appendectomy client of five hours whois 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

A male client who has severeburnsis receiving H2 receptor antagonisttherapy. The nurse Incharge knows the purpose of this therapy is to:a . P r e v e n t s t r e s s u l c e r b.Block prostaglandin synthesisc . F a c i l i t a t e protein synthesis.d.Enhance gas e x c h a n g e 8.The doctor orders hourly urine output

measurement for a postoperativemale client. The nurse Trish records the following amounts of output for 2consecutive 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 rateb.Irrigate the indwelling urinary catheter c . N o t i f y t h e p h y s i c i a n d.Continue to monitor and record hourly urine output9.Tony, a basketball player twist his right ankle while playing on the courtand seeks care for ankle pain and swelling. After the nurse applies ice tothe ankle for 30 minutes, which statement by Tony suggests that iceapplication has been effective?a.―My ankle looks less swollen now‖.b . ― M y a n k l e feels warm‖. c.―My ankle appears r e d d e r n o w ‖ . d.―I need something stronger for pain relief‖ 10.The physician prescribes a

loop diuretic for a client. When administeringthis drug, the nurse anticipates that the client may develop whichelectrolyte imbalance?a . H y p e r n a t r e m i a b.Hyperkalemiac. H ypo k a l e m i a d.Hypervolemi a 11.She finds out that some managers have benevolentauthoritative 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 nursinga.Provides continuous, coordinated and comprehensive nursingservices.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 × 3days?"a . S i n g l e o r d e r b.Standard written order c . S t a n d i n g order d. S t a t o r d e r 14.A female client with a fecal impaction frequently exhibits which clinicalmanifestation?a . I n c r e a s e d a p p e t i t e b.Loss of urge to defecatec.Hard, brown, formed stoolsd.Liquid or semi-liquid stools 15.Nurse Linda prepares to perform an otoscopic examination on a femaleclient. For proper visualization, the nurse should position the client's ear by:a.Pulling the lobule down and backb.Pulling the helix up and forwardc . P u l l i n g t h e h e l i x u p a n d b a c k d.Pulling the lobule down and forward

16. Which instruction should nurse Tom give to a male client who is havingexternal radiation therapy:a.Protect the irritated skin from sunlight.b.Eat 3 to 4 hours before treatment.c . W a s h t h e s k i n o v e r r e g u l a r l y . 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 isaware 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 aholiday celebration of excessive food and alcohol. Which assessmentfinding reflects this diagnosis?a.Blood pressure above normal

range.b.Presence of crackles in both lung fields.c . H y p e r a c t i v e b o w e l s o u n d s d.Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement incaring for the client withburns?a.Provide highfiber, high-fat dietb.Provide high-protein, highcarbohydrate 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 priorityinformation should the nurse have about the client?a.Blood pressure and pulse rate. b.Height and w e i g h t . c.Calcium and potassium levelsd . H g b a n d H c t l e v e l s . 21. Nurse Michelle witnesses a female client sustain a fall and suspects thatthe leg

may be broken. The nurse takes which priority action?a . T a k e s a s e t o f v i t a l s i g n s . b.Call the radiology department for Xray.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 wouldtake 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. Thenurse formulates which priority nursing diagnosis?a . C o n s t i p a t i o n b . D i a r r h e a c.Risk for i n f e c t i o n d.Deficient k n o w l e d g e 24.A male client is receiving total parenteral nutrition

suddenly demonstratessigns and symptoms of an air embolism. What is the priority action by thenurse?a . N o t i f y t h e p h y s i c i a n . b.Place the client on the left side in the Trendelenburg position.c.Place the client in high-Fowlers position.d.Stop the total parenteral nutrition.25.Nurse May attends an educational conference on leadership styles. Thenurse is sitting with a nurse employed at a large trauma center who statesthat the leadership style at the trauma center is task-oriented anddirective. The nurse determines that the leadership style used at thetrauma center is:a . A u t o c r a t i c . b . L a i s s e z -faire. c.Democratic. d.Situati o n a l 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. Thenurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10cc. How many cc’s of KCl

will be added to the IV solution?a . . 5 c c c . 1 . 5 c c b . 5 c c d . 2 . 5

c c 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift.The IV drip factor is 60. The IV rate that will deliver this amount is:a . 5 0 c c / hour b.55 cc/ hour c.24 cc/ hour d.66 cc/ h o u r 28.The nurse is aware that the most important nursing action when a clientreturns from surgery is:a.Assess the IV for type of fluid and rate of flow.b.Assess the client for presence of pain.c.Assess the Foley catheter for patency and urine outputd.Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicatecardiogenic shock after myocardial infarction?a.BP – 80/60, Pulse – 110 irregular b .B P – 9 0 /5 0 ,

P u l s e – 5 0 r e g ul ar c. B P – 130 /80 , P ul se – 1 0 0 r eg ul ar d.BP – 180/100, Pulse – 90 irregular 30.Which is the most appropriate nursing action in obtaining a blood pressuremeasurement?a.Take the proper equipment, place the client in a comfortableposition, and record the appropriate information in the client’s chart.b.Measure the client’s arm, if you are not sure of the size of cuff touse.c.Have the client recline or sit comfortably in a chair with the forearmat the level of the heart d.Document the measurement, which extremity was used, and theposition that the client was in during the measurement.31.Asking the questions to determine if the person understands the healthteaching provided by the nurse would be included during which step of thenursing process? a.

Assessment b. Evaluation c. Implementationd . P l a n n i n g a n d g o a l s 32.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 .D i a gn osti c t est r es ul t s b . B i o g r a p h i c a l d a t e c.H i st or y of pr e s ent i l l n ess d. Physical examination33.In preventing the development of an external rotation deformity of the hipin a client who must remain in bed for any period of time, the mostappropriate nursing action would be to use:a.Trochanter roll extending from the crest of the ileum to the midthigh.b .P i l l ows u n der t he l ow er l e gs. c . F o o t b o a r d d .H i p-

a b du ct or pi l l ow 34.Which stage of pressure ulcer development does the ulcer extend into thesubcutaneous tissue?a . S t a g e I b.Stage IIId.Stage IIc.Stage I V 35.When

neck v e i n s d . T a c h y c a r d i a 37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hoursas needed, to control a client’s postoperative pain. The package insert is―Meperidine, 100 mg/ml.‖ How many milliliters of meperidine should theclient receive?a . 0 . 7 5 b . 0 . 6 c . 0 . 5 d . 0 . 2 5 38. A male client withdiabetes mellitusis receiving insulin. Which statementcorrectly describes an insulin unit?a.It’s a common measurement in the metric system.b.It’s the basis for solids in the avoirdupois system.c.It’s the smallest measurement in the apothecary system. d.It’s a measure of effect, not a standard measure of weight or quantity.39.Nurse Oliver measures a client’s temperature at 102° F. What is theequivalent Centigrade temperature?a . 4 0 . 1

the method of wound healing is one in which wound edges are notsurgically approximated and integumentary continuity is restored bygranulations, the wound healing is termeda .S e co n d i nt e nt i on h e al i n g b.P r i mar y i nt e nt i o n h e al i n g c .T hi r d i nt e nt i on h e al i n g d . Fi r st i nt ent i o n h e al i n g 36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t beeneating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:a . H y p o t h e r m i a b . H y p e r t e n s i o n c.Distended

° C b . 3 8 . 9 ° C d . 3 8

° C c . 4 8 ° C 40.The nurse

of the chest.42.Nurse Trish must verify the client’s identity before administeringmedication. She is aware that the safest way to verify identity is to:a.Check the client’s identification band.b.Ask the client to state his name.c.State the client’s name out loud and wait a client to repeat it.d.Check the room number and the client’s name on the bed.43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V.infusion at a rate of:a . 3 0 drops/minuteb.32 drops/minutec . 2 0 dr o p s /m i n u t e d.18 d r o p s / m i n u t e 44.If a central venous catheter becomes disconnected accidentally, whatshould the nurse in-charge do immediately?a . C l a m p t h e catheter b.Call another nursec.Call the p h y s i c i a n d.Apply a dry

sterile dressing to the site.45.A female client was recently admitted. She has fever, weight loss, andwatery diarrhea is being admitted to the facility. While assessing the client,Nurse Hazel inspects the client’s abdomen and notice that it is slightlyconcave. Additional assessment should proceed in which order:a.Palpation, auscultation, and percussion.b.Percussion, palpation, and auscultation.c.Palpation, percussion, and auscultation.d.Auscultation, percussion, and palpation. 46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the:a . F i n g e r t i p s b . F i n g e r p a d s c . D or sal s ur f a ce of t he ha n dd .Ul nar s ur f a ce of t he ha n d 47. Which type of evaluation occurs continuously throughout the teaching andlearning process?a . S u m m a t i v e b . I n f

ormativec . F o r m a t i v e d . R e t r o s p e c t i v e 48.A 45 year old client, has no family history of breast cancer or other riskfactors for this disease. Nurse John should instruct her to havemammogram how often?a . T w i c e p e r year b.Once per year c.E ver y 2 y e a r s d . On c e , t o e st a bl i sh b as el i ne 49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,Nurse Patricia should expect which condition?a. Re spi r at or y a ci d o si s b .R es pi r at or y al k al o si s c . M e t a b o l i c acidosisd.Metabolic a l k a l o s i s 50.Nurse Len refers a female client with terminal cancer to a local hospice.What is the goal of this referral?a.To help the client find appropriate treatment options.b.To provide support for the client and family in coping with terminalillness.c.To

is assessing a 48-year-old client who has come to thephysician’s office for his annual physical exam. One of the first physicalsigns of aging is:a.Accepting limitations while developing assets.b.Increasing loss of muscle tone.c.Failing eyesight, especially close vision. d.Having more frequent aches and pains.41.The physician inserts a chest tube into a female client to treat apneumothorax. The tube is connected to water-seal drainage. The nursein-charge can prevent chest tube air leaks by:a.Checking and taping all connections.b.Checking patency of the chest tube.c.Keeping the head of the bed slightly elevated.d.Keeping the chest drainage system below the level

ensure that the client gets counseling regarding health carecosts.d.To teach the client and family about cancer and its treatment. 51.When caring for a male client with a 3-cm stage I pressure ulcer on thecoccyx, which of the following actions can the nurse instituteindependently?a.Massagin g the area with an astringent every 2 hours.b.Applying an antibiotic cream to the area three times per day.c.Using normal saline solution to clean the ulcer and applying aprotective dressing as necessary.d.Using a povidone-iodine wash on the ulceration three times per day.52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. Heshould apply the bandage beginning at the client’s:a . K n e e b . A n k l e c.Lower t h i g h d . F o o t 53.A 10 year old child with type 1 diabetes

develops diabetic ketoacidosisand receives a continuous insulin infusion. Which condition represents thegreatest risk to this child?a . H y p e r n a t r e m i a b . H y p o k a l e m i a c.Hyperphosp hatemiad . H y p e r c a l c e m i a 54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newlyadmitted client. Immediately afterward, the client may experience:a.Throbbing headache or dizzinessb .N er v ou sne ss or p ar est he si a . c.Dr owsi ne ss or bl ur r e d vi si o n. d .T i n ni t us or di pl opi a. 55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nursequickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching theclient’s bedside, the nurse would take which action first?a .P r e par e for c ar di over si o n b.Prepare to defibrillate the clientc . C a l l

a c o d e d.Check the client’s level of consciousness 56.Nurse Hazel is preparing to ambulate a female client. The best and thesafest position for the nurse in assisting the client is to stand:a.On the unaffected side of the client.b.On the affected side of the client.c . I n f r o n t o f t h e client.d.Behind the c l i e n t . 57.Nurse Janah is monitoring the ongoing care given to the potential organdonor who has been diagnosed with brain death. The nurse determinesthat the standard of care had been maintained if which of the followingdata is observed?a .U r i ne o ut pu t: 45 ml / hr b . Ca pi l l ar y r ef i l l : 5 s e co n ds c . S e r u m p H : 7 . 3 2 d .B l o o d pr ess ur e: 90 /48 mm Hg 58. Nurse Amy has an order to obtain aurinalysisfrom a male client with

anindwelling urinary catheter. The nurse avoids which of the following, whichcontaminate the specimen?a.Wiping the port with an alcohol swab before inserting the syringe.b.Aspirating a sample from the port on the drainage bag.c.Clamping the tubing of the drainage bag.d.Obtaining the specimen from the urinary drainage bag.59.Nurse Meredith is in the process of giving a client a bed bath. In themiddle of the procedure, the unit secretary calls the nurse on the intercomto tell the nurse that there is an emergency phone call. The appropriatenursing action is to:a.Immediately walk out of the client’s room and answer the phonecall.b.Cover the client, place the call light within reach, and answer thephone call.c.Finish the bed bath before answering the phone call. d.Leave the client’s door open so the client can be

monitored and thenurse can answer the phone call.60. Nurse Janah is collecting a sputum specimen for culture and sensitivitytesting from a client who has a productive cough. Nurse Janah plans toimplement which intervention to obtain the specimen?a.Ask the client to expectorate a small amount of sputum into theemesis basin. b.Ask the client to obtain the specimen after breakfast.c.Use a sterile plastic container for obtaining the specimen.d.Provide tissues for expectoration and obtaining the specimen.61. Nurse Ron is observing a male client using a walker. The nursedetermines that the client is using the walker correctly if the client:a.Puts all the four points of the walker flat on the floor, puts weight onthe hand pieces, and then walks into it.b.Puts weight on the hand pieces, moves the

walker forward, andthen walks into it.c.Puts weight on the hand pieces, slides the walker forward, and thenwalks into it.d.Walks into the walker, puts weight on the hand pieces, and thenputs all four points of the walker flat on the floor.62.Nurse Amy has documented an entry regarding client care in the client’smedical record. When checking the entry, the nurse realizes that incorrectinformation was documented. How does the nurse correct this error?a.Erases the error and writes in the correct information.b.Uses correction fluid to cover up the incorrect information andwrites in the correct information.c.Draws one line to cross out the incorrect information and theninitials the change.d.Covers up the incorrect information completely using a black penand writes in the correct information63.Nurse Ron is assisting with transferring a client from the operating roomtable to a stretcher.

To provide safety to the client, the nurse should:a.Moves the client rapidly from the table to the stretcher.b.Uncovers the client completely before transferring to the stretcher.c.Secures the client safety belts after transferring to the stretcher.d.Instructs the client to move self from the table to the stretcher.64.Nurse Myrna is providing instructions to a nursing assistant assigned togive a bed bath to a client who is on contact precautions. Nurse Myrnainstructs the nursing assistant to use which of the following protectiveitems when giving bed bath?a . G o w n a n d gogglesb.Gown and g l o v e s c.G l ov es a nd s ho e p r ot e ct or s d . G l o v e s a n d goggles 65. Nurse Oliver is caring for a client with impaired mobility that occurred as aresult of a stroke. The client has right sided arm and leg weakness. Thenurse would suggest that the

client use which of the following assistivedevices that would provide the best stability for ambulating?a . C r u t c h e s b. Si n g l e st r ai ght - l e g g ed c a ne c . Q u a d caned . W a l k e r 66.A male client with a right pleural effusion noted on a chest X-ray is beingprepared for thoracentesis. The client experiences severe dizziness whensitting upright. To provide a safe environment, the nurse assists the clientto which position for the procedure?a.Prone with head turned toward the side supported by a pillow.b.Sims’ position with the head of the bed flat.c.Right side-lying with the head of the bed elevated 45 degrees.d.Left side-lying with the head of the bed elevated 45 degrees.67.Nurse John develops methods for data gathering. Which of the followingcriteria of a good instrument refers to the ability of the instrument to yieldthe same results upon its repeated

administration?a . V a l i d i t y b . Specificityc .Sen s i t i v it y d . R e l i a b i l i t y 68.Harry knows that he has to protect the rights of human research subjects.Which of the following actions of Harry ensures anonymity?a.Keep the identities of the subject secretb. O btai n i n for m e d c o ns e nt c.Provide equal treatment to all the subjects of the study.d.Release findings only to the participants of the study 69.Patient’s refusal to divulge information is a limitation because it is beyondthe control of Tifanny‖.What type of research is appropriate for this study?a .D es cr i pti v e c or r el a ti o nal b . E x p e r i m e n t c.Quasiexperimentd . H i s t o r i c a l 70.Nurse Ronald is aware that the best tool for data gathering is?a . I n t e r v i e w scheduleb . Q u e s t i o n n a i r e c.Use of laboratory

d a t a d . O b s e r v a t i o n 71.Moni ca is aware that there are times when only manipulation of studyvariables is possible and the elements of control or randomization are notattendant. Which type of research is referred to this?a . F i e l d s t u d y b.Quasie x p e r i m e n t c. Sol omo n F our gr o u p d esi g nd. P os t t est onl y de si gn 72.Cherry notes down ideas that were derived from the description of aninvestigation written by the person who conducted it. Which type of reference source refers to this?a . F o o t n o t e b . B i b l i o graphyc.Primary s o u r c e d . E n d n o t e s 73.Wh en Nurse Trish is providing care to his patient, she must remember thather duty is bound not to do doing any action that will cause the patientharm. This is the meaning of the bioethical principle:a . N o n maleficenceb . B e ne f i c e n cec . J u s t i c e d.Sol i da r

i t y 74.When a nurse in-charge causes an injury to a female patient and the injurycaused becomes the proof of the negligent act, the presence of the injuryis said to exemplify the principle of:a . F o r c e m a j e u r e b .R es po n de at s u per i or c . R e s i p s a loquitor d.Holdover doctrine 75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power.An example of this power is:a.The Board can issue rules and regulations that will govern thepractice of nursingb.The Board can investigate violations of the nursing law and code of ethicsc.The Board can visit a school applying for a permit in collaborationwith CHEDd.The Board prepares the board examinations 76. When the license of nurse Krina is revoked, it means that she:a.Is no longer allowed to practice the profession for the rest of her

lifeb.Will never have her/his license re-issued since it has been revokedc.May apply for reissuance of his/her license based on certainconditions stipulated in RA 9173d.Will remain unable to practice professional nursing77.Ronald plans to conduct a research on the use of a new method of painassessment scale. Which of the following is the second step in theconceptualizing phase of the research process?a.Formulating the research hypothesisb .R ev i ew r el at e d l i t er a t ur e c.Formulating and delimiting the research problemd.Design the theoretical and conceptual framework 78. The leader of the study knows that certain patients who are in aspecialized research setting tend to respond psychologically to theconditions of the study. This referred to as :a . C a u s e a n d

effectb.Hawthorne effectc . H a l o effect d.Horns e f f e c t 79.Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct?a.Plans to include whoever is there during his study.b.Determines the different nationality of patients frequently admittedand decides to get representations samples from each.c.Assigns numbers for each of the patients, place these in a fishbowland draw 10 from it. d. Decides to get 20 samples from the admitted patients 80. The nursing theorist who developed transcultural nursing theory is: a. Fl or e n ce N i ght i n gal e b. Ma d el e i n e L ei ni ng er c . A l b e r t M o o r e d.Sr. Callista R o y 81.Marion is aware that the sampling method that gives equal chance to allunits in the population

to get picked is: a . R a n d o m b . A c c i d e ntalc . Q u o t a d.Judg m e n t 82.John plans to use a Likert Scale to his study to determine the: a.Degree of agreement and disagreementb.Compliance to expected standardsc .L ev el of s at i s fa cti on d .D e gr ee o f a c c ep tan c e 83.Which of the following theory addresses the four modes of adaptation?a . Ma del ei ne L ei ni ng er b . S r . C a l l i s t a Royc.Florence Nightingaled . J e a n W a t s o n 84.Ms. Garcia is responsible to the number of personnel reporting to her. Thisprinciple refers to:a . S p a n o f c o n t r o l b.Unity of c o m m a n d c .D ow nwar d c o mmu ni c a ti o n d . L e a d e r 85.Ensuring that there is an informed consent on the part of the patientbefore a surgery is done, illustrates the bioethical principle

of:a . B e n e f i c e n c e b . A u t o n o m y c . V e r a c i t y d.No n-maleficence 86.Nurse Reese is teaching a female client with peripheral vascular diseaseabout foot care; Nurse Reese should include which instruction?a .A vo i d w ear i n g c o tto n so ck s. b.Avoid using a nail clipper to cut toenails.c .A vo i d w ear i ng c a nva s sh oe s. d.Avoid using cornstarch on feet.87.A client is admitted with multiple pressure ulcers. When developing theclient's diet plan, the nurse should include:a . F r e s h o r a n g e slicesb.Steamed broccolic . I c e c r e a m d.Ground beef p a t t i e s 88.The nurse prepares to administer a cleansing enema. What is the mostcommon client position used for this procedure?a . L i t h o t o m y b . S u p i n e c . P r o n e d.Si m s ’ l e f t l a t e r a l 89.Nurse

Marian is preparing to administer a blood transfusion. Which actionshould the nurse take first?a.Arrange for typing and cross matching of the client’s blood.b.Compare the client’s identification wristband with the tag on the unitof blood.c.Start an I.V. infusion of normal saline solution.d.Measure the client’s vital signs. 90.A 65 years old male client requests his medication at 9 p.m. instead of 10p.m. so that he can go to sleep earlier. Which type of nursing interventionis required?a . I n d e p e n d e n t b . D epende nt c.Interdepe n d e n t d . I n t r a d e p e n d e n t 91 .A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that theclient's leg is pain-free, without redness or edema. The nurse's actionsreflect which step of the nursing process?

and nausea whilereceiving tube a.Assessmentb.Diagn os i s c.Implementationd . E v a l u a t i o n 92.Nursing care for a female client includes removing elastic stockings onceper day. The Nurse Betty is aware that the rationale for this intervention?a.To increase blood flow to the heartb.To observe the lower extremitiesc.To allow the leg muscles to stretch and relaxd.To permit veins in the legs to fill with blood.93.Which nursing intervention takes highest priority when caring for a newlyadmitted client who's receiving a blood transfusion?a.Instructing the client to report any itching, swelling, or dyspnea.b.Informing the client that the transfusion usually take 1 ½ to 2 hours.c.Documenting blood administration in the client care record.d.Assessing the client’s vital signs when the transfusion ends.94.A male client complains of abdominal discomfort feedings. Which intervention is most appropriate for thisproblem?a.Give the feedings at room temperature.b.Decrease the rate of feedings and the concentration of the formula.c.Place the client in semi-Fowler's position while feeding.d.Change the feeding container every 12 hours.95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should:a . D o n o t h i n g . b.Invert the vial and let it stand for 3 to 5 minutes.c. Shak e t he vi al vi g or o usl y . d.Roll the vial gently between the palms.96.Which intervention should the nurse Trish use when administering oxygenby face mask to a female client?a.Secure the elastic band tightly around the client's head.b.Assist the client to the semi-Fowler position if

possible.c.Apply the face mask from the client's chin up over the nose. d.Loosen the connectors between the oxygen equipment andhumidifier.97.The maximum transfusion time for a unit of packed red blood cells (RBCs)is:a . 6 h o u r s b . 4 h o u r s c . 3 h o u r s d . 2 h o u r s 98.Nurse Monique is monitoring the effectiveness of a client's drug therapy.When should the nurse Monique obtain a blood sample to measure thetrough drug level?a.1 hour before administering the next dose.b.Immediately before administering the next dose.c.Immediately after administering the next dose.d.30 minutes after administering the next dose.99.Nurse May is aware that the main advantage of using a floor stock systemis:a.The nurse can

implement medication orders quickly.b.The nurse receives input from the pharmacist.c.The system minimizes transcription errors.d.The system reinforces accurate calculations.100.Nurse Oliver is assessing a client's abdomen. Which finding should thenurse report as abnormal?a. Dul l ne ss o ver t h e l i v er . b.Bowel sounds occurring every 10 seconds.c.Shifting dullness over the abdomen.d.Vascular sounds heard over the renal arteries TEST II - Community Health Nursing and Care of the Mother and Child 1.May arrives at the health care clinic and tells the nurse that her lastmenstrual period was 9 weeks ago. She also tells the nurse that a homepregnancy test was positive but she began to have mild cramps and isnow having moderate vaginal bleeding. During the physical

examination of the client, the nurse notes that May has a dilated cervix. The nursedetermines that May is experiencing which type of abortion?a . I n e v i t a b l e b . I n completec.Threatene d d . S e p t i c 2.Nurse Reese is reviewing the record of a pregnant client for her firstprenatal visit. Which of the following data, if noted on the client’s record,would alert the nurse that the client is at risk for a spontaneous abortion?a . A g e 3 6 y e a r s b.History of s y p h i l i s c .Hi st or y of g e ni t al h er p es d .H i st or y of d i a be te s mel l i tu s 3.Nurse Hazel is preparing to care for a client who is newly admitted to thehospital with a possible diagnosis of ectopic pregnancy. Nurse Hazeldevelops a plan of care for the client and determines that which of thefollowing nursing actions is the priority?a . M o n i t o r i n g weightb.Assessing for e d e m a c . Mo ni t or i n g a pi cal

p ul se d .M on i tor i n g t em per atur e 4.Nurse Oliver is teaching a diabetic pregnant client about nutrition andinsulin needs during pregnancy. The nurse determines that the clientunderstands dietary and insulin needs if the client states that the secondhalf of pregnancy require:a .D e cr ea se d cal or i c i nt ak eb .I n cr eas ed cal or i c i nt ak e c . D e c r e a s e d Insulind.Increase Insulin 5.Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociatedwith this condition?a.E x c ess i ve fe tal a ct i vi t y. b.Larger than normal uterus for gestational age.c . V a g i n a l b l e e d i n g d.Elevated levels of human chorionic gonadotropin.6.A pregnant client is receiving magnesium sulfate for severe pregnancyinduced hypertension

(PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:a .U r i n ar y ou t p ut 90 c c i n 2 ho ur s .b .A b s ent p at el l ar r efl ex es . c.Rapid respiratory rate above 40/min.d .R ap i d r i se i n b l o o d pr ess ur e . 7.During vaginal examination of Janah who is in labor, the presenting part isat station plus two. Nurse, correctly interprets it as:a.Presenting part is 2 cm above the plane of the ischial spines.b.Biparietal diameter is at the level of the ischial spines.c.Presenting part in 2 cm below the plane of the ischial spines.d.Biparietal diameter is 2 cm above the ischial spines.8.A pregnant client is receiving oxytocin (Pitocin) for induction of labor. Acondition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:a.Contractions every 1 ½ minutes lasting 70-80 seconds.b . Mat er nal

t em per at ur e 1 0 1 .2 c.Early decelerations in the fetal heart rate.d.Fetal heart rate baseline 140-160 bpm.9.Calcium gluconate is being administered to a client with pregnancyinduced hypertension (PIH). A nursing action that must be initiated as theplan of care throughout injection of the drug is:a. V ent i l at or a ssi st an c e b . C V P readingsc.E KG t r a c i n g s d.Continuous CPR 10. A trial for vaginal delivery after an earlier caesareans, would likely to begiven to a gravida, who had:a.First low transverse cesarean was for active herpes type 2infections; vaginal culture at 39 weeks pregnancy was positive.b.First and second caesareans were for cephalopelvic disproportion.c.First caesarean through a classic incision as a

result of severe fetaldistress.d.First low transverse caesarean was for breech position. Fetus inthis pregnancy is in a vertex presentation.11.Nurse Ryan is aware that the best initial approach when trying to take acrying toddler’s temperature is:a.Talk to the mother first and then to the toddler.b.Bring extra help so it can be done quickly.c.Encourage the mother to hold the child.d.Ignore the crying and screaming.12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. Whatshould the nurse do to prevent trauma to operative site?a.Avoid touching the suture line, even when cleaning.b.Place the baby in prone position.c .G i v e t he b a by a pa ci fi er . d.Place the infant’s arms in soft elbow restraints. 13. Which action should nurse Marian include in thecare planfor a 2

monthold with heart failure?a .F e ed t he i n fan t wh en he c r i es . b.Allow the infant to rest before feeding.c.Bathe the infant and administer medications before feeding.d.Weigh and bathe the infant before feeding.14.Nurse Hazel is teaching a mother who plans to discontinue breast feedingafter 5 months. The nurse should advise her to include which foods in her infant’s diet?a. Sk i m mi l k an d b a by f o od . b.W ho l e mi l k an d b a by fo od . c .Ir on - r i ch f or m ul a onl y . d.Iron-rich formula and baby food.15.Mommy Linda is playing with her infant, who is sitting securely alone onthe floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infantwould be:a . 6 monthsb.4

monthsc.8 monthsd.10 m o n t h s 16.Which of the following is the most prominent feature of public healthnursing?a.It involves providing home care to sick people who are not confinedin the hospital.b.Services are provided free of charge to people within thecatchments area.c.The public health nurse functions as part of a team providing apublic health nursing services.d.Public health nursing focuses on preventive, not curative, services.17.When the nurse determines whether resources were maximized inimplementing Ligtas Tigdas, she is evaluatinga . E f f e c t i v e n e s s b . Efficiencyc.Adequacy d . A p p r o p r i a t e n e s s 18.Vangie is a new B.S.N. graduate. She wants to become a Public HealthNurse. Where should she apply?a .D epar tm ent of H eal t h b.P r ovi nc i al H eal t h O f fi ce c .R e gi o nal H eal t h

O f fi ce d . R u r a l H e a l t h U n i t 19.Tony is aware the Chairman of the Municipal Health Board is: a . M a y o r b. M u ni ci pal H eal t h O ff i cer c . P u b l i c H e a l t h N u r s e d. A ny qu al i fi e d p h ysi c i an 20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHUpersonnel. How many more midwife items will the RHU need? a.1b. 2c. 3d. The RHU does not need any more midwife item.21.According to Freeman and Heinrich, community health nursing is adevelopmental service. Which of the following best illustrates thisstatement?a.The community health nurse continuously develops himself personally and professionally.b.Health education and community organizing are necessary inproviding community health services.c.Community health

nursing is intended primarily for health promotionand prevention and treatment of disease.d.The goal of community health nursing is to provide nursing servicesto people in their own places of residence.22.Nurse Tina is aware that the disease declared through PresidentialProclamation No. 4 as a target for eradication in the Philippines is?a . P o l i o m y e l i t i s b . M e aslesc . R a b i e s d. N e o n a t a l t e t a n u s 23.May knows that the step in community organizing that involves training of potential leaders in the community is:a . I n t e g r a t i o n b . C o mmu ni t y or ga ni z at i o n c . C o m m u n i t y s t u d y d. C or e g r o up for mati on 24.Beth a public health nurse takes an active role in community participation.What is the primary goal of community organizing?a.To educate the people regarding community health problemsb.To mobilize the people to resolve

community health problemsc.To maximize the community’s resources in dealing with healthproblems.d.To maximize the community’s resources in dealing with healthproblems. 25.Tertiary prevention is needed in which stage of the natural history of disease?a . P r e pathogenesisb . P a t h o g e nesisc . P r o d r o m a l d . T e r m i n a l 26.The nurse is caring for a primigravid client in the labor and delivery area.Which condition would place the client at risk for disseminatedintravascular coagulation (DIC)?a. Intr au ter i n e f et al d eat h .b . P l a c e n t a accreta.c.Dysfunctional l a b o r . d.Premature rupture of the membranes.27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart ratewould be:a .8 0 t o 100 b e at s /mi nu te b .100 to 12 0 b e at s /mi nu te c .120 to 16 0 b e at s /mi nu te d .160 to 18 0

b e ats /mi nu te 28.The skin in the diaper area of a 7 month old infant is excoriated and red.Nurse Hazel should instruct the mother to:a. C ha ng e t he di a pe r m or e oft e n. b.Apply talc powder with diaper changes.c.Wash the area vigorously with each diaper change.d.Decrease the infant’s fluid intake to decrease saturating diapers.29.Nurse Carla knows that the common cardiac anomalies in children withDown Syndrome (tri-somy 21) is:a .A t r i a l s e ptal de f e ct b . P u l m o n i c s t e n o s i s c. V en tr i cul ar s e ptal de f e ctd .E nd oc ar di al c u sh i o n d ef e ct 30.Malou was diagnosed with severe preeclampsia is now receiving I.V.magnesium sulfate. The adverse effects associated with magnesiumsulfate is:a . A n e m i a b . De cr eas e d ur i n e o ut pu t c . H y p e r r e f l e x i a d .I n cr ea se d r esp i r at or y

r at e 31.A 23 year old client is having her menstrual period every 2 weeks that lastfor 1 week. This type of menstrual pattern is bets defined by:a . M e n o r r h a g i a b . M e t r orrhagiac.Dys pa r euni a d . A m e n o r r h e a 32.Jannah is admitted to the labor and delivery unit. The critical laboratoryresult for this client would be:a . O x y g e n s a t u r a t i o n b. Ir o n bi n d i n g c a pa ci t y c . B l o o d t ypi ng d.Serum C a l c i u m 33.Nurse Gina is aware that the most common condition found during thesecond-trimester of pregnancy is:a . M e t a b o l i c a l k a l o s i s b. Re spi r at or y a ci d osi s c . M a s t i t i s d . P h y s i o l o g i c a n e m i a 34.Nurse Lynette is working in the triage area of an emergency department.She sees that several pediatric clients arrive simultaneously. The clientwho needs to be treated first is:a.A crying 5 year old child with a laceration on his scalp.b.A 4 year old child with a barking

coughs and flushed appearance.c.A 3 year old child with Down syndrome who is pale and asleep inhis mother’s arms.d.A 2 year old infant with stridorous breath sounds, sitting up in hismother’s arms and drooling.35.Maureen in her third trimester arrives at the emergency room with painlessvaginal bleeding. Which of the following conditions is suspected?a . P l a c e n t a previab.Abruptio placentaec . P r e m a t u r e l a b o r d.Sexually transmitted disease 36.A young child named Richard is suspected of having pinworms. Thecommunity nurse collects a stool specimen to confirm the diagnosis. Thenurse should schedule the collection of this specimen for:a . J u s t b e f o r e b e d t i m e b .A ft er t he c hi l d h as be en bat h e c . A n y t i m e during the dayd.Early in t h e m o r n i n g 37.In doing a

child’s admission assessment, Nurse Betty should be alert tonote which signs or symptoms of chronic lead poisoning?a .Ir r i ta bi l i t y a nd s ei z ur e sb .D eh y dr ati o n a n d d i ar r he a c.B r ad y car di a a n d h y p ot e nsi on d .P e te ch i a e a n d h emat ur i a 38.To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use theappliance. Which response indicates a need for further health teaching?a.―I should check the diaphragm carefully for holes every time I use it‖b.―I may need a different size of diaphragm if I gain or lose weightmore than 20 pounds‖c.―The diaphragm must be left in place for atleast 6 hours after intercourse‖d.―I really need to use the diaphragm and jelly most during the middleof my menstrual cycle‖.39.Hypoxia is a common complication of laryngotracheobronchitis. NurseOliver should frequently assess a child with

laryngotracheobronchitis for:a . D r o o l i n g b . M u f f l e d v o i c e c . R e s t l e s s n e s s d.Lo w - g r a d e f e v e r 40.How should Nurse Michelle guide a child who is blind to walk to theplayroom?a.Without touching the child, talk continuously as the child walksdown the hall.b.Walk one step ahead, with the child’s hand on the nurse’s elbow.c.Walk slightly behind, gently guiding the child forward.d.Walk next to the chi ld, holding the child’s hand. 41.When assessing a newborn diagnosed with ductus arteriosus, NurseOlivia should expect that the child most likely would have an:a.Loud, machinery-like murmur.b. B l ui sh c ol or t o t he l i ps . c.Decreased BP reading in the upper extremitiesd.Increased BP reading in the upper

extremities.42.The reason nurse May keeps the neonate in a neutral thermalenvironment is that when a newborn becomes too cool, the neonaterequires:a.Less oxygen, and the newborn’s metabolic rate increases.b.More oxygen, and the newborn’s metabolic rate decreases.c.More oxygen, and the newborn’s metabolic rate increases.d.Less oxygen, and the newborn’s metabolic rate decreases.43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sureto assess whether this infant has:a. St a bl e b l o o d pr ess ur e b . P a t a n t fontanellesc . M o r o’ s r e f l e x d . V o i d e d 44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:a . B a b y o i l b.Baby l o t i o n c.Laundry d e t e r g e n t d .P ow d er w i t h c or nst ar ch 45.During tube feeding, how far above an infant’s

stomach should the nursehold the syringe with formula?a . 6 inchesb.12 inchesc.18 inchesd.24 inches 46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases suchas chicken pox. Which of the following statements aboutchicken poxiscorrect? a.The older one gets, the more susceptible he becomes to thecomplications of chicken pox.b. A single attack of chicken pox will prevent future episodes,including conditions such as shingles.c. To prevent an outbreak in the community, quarantine may beimposed by health authorities.d. Chicken pox vaccine is best given when there is an impendingoutbreak in the community.47.Barangay Pinoy had an outbreak of German measles. To preventcongenital rubella, what is the BEST advice that you can give to

women inthe first trimester of pregnancy in the barangay Pinoy?a.Advice them on the signs of German measles.b.Avoid crowded places, such as markets and movie houses.c.Consult at the health center where rubella vaccine may be given.d.Consult a physician who may give them rubella immunoglobulin.48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertakenis:a . C o n t a c t tracingb. Community surveyc. Mass screening t e s t s d . I nt er vi ew o f s us pe c ts 49.A 33-year old female client came for consultation at the health center withthe chief complaint of fever for a week. Accompanying symptoms weremuscle pains and body malaise. A week after the start of fever, the clientnoted yellowish discoloration of his sclera. History showed that he wadedin flood

waters about 2 weeks before the onset of symptoms. Based onher history, which disease condition will you suspect? a. Hepatitis A b. Hepatitis Bc . T e t a n u s d. Leptospirosis50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of ―rice water‖ stools. Theclient is most probably suffering from which condition?a . G i a r d i a s i s b. Cholera c. Amebiasis d . D y s e n t e r y 51.The most prevalent form of meningitis among children aged 2 months to 3years is caused by which microorganism? a.H em op hi l us i nfl u enz a e b . M o r b i l l i v i r u s c.

S t e pt oc o c cu s p n eu mo ni a e d. Ne i sse r i a m en i n gi t i di s 52.The student nurse is aware that the pathognomonic sign of measles isKoplik’s spot and you may see Koplik’s spot by inspecting the:a . N a s a l mucosab.Buccal m u c o s a c.Skin on the abdomend . S k i n o n n e c k 53.Angel was diagnosed as having Dengue fever. You will say that there isslow capillary refill when the color of the nailbed that you pressed does notreturn within how many seconds?a . 3 secondsb. 6 secondsc. 9 secondsd. 10 s e c o n d s 54.In Integrated Management of Childhood Illness, the nurse is aware thatthe severe conditions generally require urgent referral to a hospital. Whichof the following severe conditions DOES NOT always require urgentreferral to a

hospital?a . M a s t o i d i t i s b . S e v ere dehydrationc.Severe p n e u m o n i a d .S ev ere f e br i l e d i se as e 55.Myrna a public health nurse will conduct outreach immunization in abarangay Masay with a population of about 1500. The estimated number of infants in the barangay would be:a . 4 5 i n f a n t s b . 5 0 infantsc.55 infants d.65 infants 56.The community nurse is aware that the biological used in ExpandedProgram on Immunization (EPI) should NOT be stored in the freezer?a . D P T b . O r a l polio vaccinec . M e a s l e s v a c c i n e d . M M R 57.It is the most effective way of controlling schistosomiasis in an endemicarea?a .Us e o f m ol l us ci ci de sb .B ui l di n g of f o ot br i d g es c.P r op er u se o f sa ni t ar y t oi l et s d.Use of protective footwear, such as rubber boots58.Several clients is newly admitted and diagnosed with

leprosy. Which of thefollowing clients should be classified as a case of multibacillary leprosy?a.3 skin lesions, negative slit skin smear b.3 skin lesions, positive slit skin smear c.5 skin lesions, negative slit skin smear d.5 skin lesions, positive slit skin smear 59.Nurses are aware that diagnosis of leprosy is highly dependent onrecognition of symptoms. Which of the following is an early sign of leprosy?a . M a c u l a r l e s i o n s b .I na bi l i t y t o cl os e e y el i ds c .T hi ck en e d p ai nf ul n er v es d .Si nk i ng of th e n os e br i dg e 60.Marie brought her 10 month old infant for consultation because of fever,started 4 days prior to consultation. In determining malaria risk, what willyou do?a .P er f or m a t our n i qu et t est . b. A sk w h er e t he fa mi l y r esi de s. c .G et a s pe ci m e n f or bl o od sme ar . d.Ask if the fever is present

everyday.61.Susie brought her 4 years old daughter to the RHU because of cough andcolds. Following the IMCI assessment guide, which of the following is adanger sign that indicates the need for urgent referral to a hospital? a.Inability to drinkb.High grade f e v e r c. Si gn s o f sev er e d e h y dr ati on d .C o ug h f or m or e t ha n 30 d ay s 62.Jimmy a 2-year old child revealed ―baggy pants‖. As a nurse, using theIMCI guidelines, how will you manage Jimmy?a.Refer the child urgently to a hospital for confinement.b.Coordinate with the social worker to enroll the child in a feedingprogram.c.Make a teaching plan for the mother, focusing on menu planning for her child.d. Assess and treat the child for health problems like infections andintestinal parasitism.63.Gina is using Oresol in the management of diarrhea

of her 3-year oldchild. She asked you what to do if her child vomits. As a nurse you will tellher to: a.Bring the child to the nearest hospital for further assessment.b.Bring the child to the health center for intravenous fluid therapy.c.Bring the child to the health center for assessment by the physician.d.Let the child rest for 10 minutes then continue giving Oresol moreslowly.64.Nikki a 5month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you willclassify this infant in which category?a. N o si gn s of d e h y dr at i on b . S o m e dehydrationc.Severe d e h y d r a t i o n d . T he d at a i s i ns uf fi ci ent . 65.Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the

Anemia probably due to chronic fetal hyposia b. Hyperglycemia due to decreased glycogen stores d. which condition would nurse Richard anticipate as a potentialproblem in the neonate? a. 32 weeks70. Increased temperature c. 2 y e a r s 69.6 monthsc .The nurse explains to a breastfeeding mother that breast milk is sufficientfor all of the baby’s nutrient needs only up to: a . hisbreathing is considered as: a . 12 weeks c. When the nurseassessing the neonate. Aspiration b. She is awarethat her baby will have protection against tetanus for a . which physical finding is expected? a. Decreased temperature d. 5 monthsb. the nurse Patricia stresses the importance of placing the neonateon his back to reduce the risk of which of the following? a. Hypoglycemia b. 1 y e a r d . 24 weeks d. Nasal flaring . 4 h o u r s c . lethargic baby b. A sleepy.Maylene had just received her 4th dose of tetanus toxoid.At t h e e n d o f t h e d a y 68.Marjorie has just given birth at 42 weeks’ gestation. 8 weeks b.Which symptom would indicate the Baby Alexandra was adaptingappropriately to extrauterine life without difficulty? a. L i f e t i m e 67. 2 h o u r s b . Suffocation d. F a s t b .Which finding might be seen in baby James a neonate suspected of having an infection? a. Polycythemia probably due to chronic fetal hypoxia73. Tachycardia75. Gastroesophageal reflux (GER)71. Increased activity level72.Nurse Ron is aware that the gestational age of a conceptus that isconsidered viable (able to live outside the womb) is: a. S l o w c . 8 h o u r s d. Hyperthermia due to decreased glycogen stores c. N o r m a l d. 5 y e a r s d.When teaching parents of a neonate the proper position for the neonate’ssleep.Nurse Ron is aware that unused BCG should be discarded after howmany hours of reconstitution?a .IntegratedManagement of Child Illness (IMCI) guidelines of assessment. Flushed cheeks b. 1 y e a r b . Sudden infant death syndrome (SIDS) c. Jitteriness c.After reviewing the Myrna’s maternal history of magnesium sulfate duringlabor. Lanugo covering the body c. 3 y e a r s c . Vernix caseosa covering the body74.Baby Jenny who is small-for-gestation is at increased risk during thetransitional period for which complication? a.Insignifica nt 66. Respiratory depression d. Desquamation of the epidermis d.

T o ass es s for p r ol aps e d cor d c.―What is your expected due date?‖d.To determine fetal well-being.Dr.To prepare for an imminent delivery. When teaching umbilical cord care for Jennifer a new mother.d. Bulging fontanelle78.b.d.c. Following this procedure. When a client states that her "water broke.d.The parent’s expression of interest about the size of the new born. Cystic hygroma d.79.Provide oxygen via face mask as ordered d. Within several hours she developsrespiratory .c. What should the nursedo first? a.Observing the pooling of straw-colored fluid. N ot i f y t h e p h ysi c i an . Which of thefollowing findings is considered common in the healthy neonate? a. To a sse ss f et al p osi t i o n d. examination of the client's vagina revealsa fourth-degree laceration. the nurseJenny would include which information? a.―Who will be with you during labor?‖ 82. c.The parents’ interactions with each other. Light audible grunting c." which of the following actionswould be inappropriate for the nurse to do?a.Instructing the client on the use of sitz baths if ordered. she has no spontaneousrespirations but is successfully resuscitated. Respiratory rate 60 to 80 breaths/minute76.― Do yo u h av e a n y al l er gi es ?‖ c. Which question should the nurse Oliver ask her first?a. A baby girl is born 8 weeks premature.77.The parents’ willingness to touch and hold the new born.b. At birth.b. Conjunctival hemorrhage c. Wash the cord with soap and water each day during a tub bath.Instructing the client to use two or more peripads to cushion thearea.Conducting a bedside ultrasound for an amniotic fluid index.84.Nurse John is performing an assessment on a neonate.c. 83. Apply peroxide to the cord with each diaper change b. Esteves decides to artificially rupture the membranes of a mother whois on labor.Instructing the client about the importance of perineal (kegel)exercises.A neonate begins to gag and turns a dusky color.Calm the n e o n a t e .Checking vaginal discharge with nitrazine paper. seeks admission to thelabor and delivery area.b. b. Keep the cord dry and open to air d.Aspirate the neonate’s nose and mouth with a bulb syringe. b.Which of the following would be least likely to indicate anticipated bondingbehaviors by new parents?a. Cover the cord with petroleum jelly after bathing c.Applying cold to limit edema during the first 12 to 24 hours. She states that she's in labor and says she attended thefacility clinic for prenatal care. Simian crease b.Observing for flakes of vernix in the vaginal discharge. Which of the following would becontraindicated when caring for this client?a.The parents’ indication that they want to see the newborn. Respiratory rate 40 to 60 breaths/minute d.―Do you have any chronic illnesses?‖b .Following a precipitous delivery. A pregnant woman accompanied by her husband. the nurse Hazel checks the fetalheart tones for which the following reasons?a.81.80.

vomiting. b. 24 year-old is 27 weeks’ pregnant arrives at her physician’s officewith complaints of fever. Nurse John is knowledgeable that usually individual twins will growappropriately and at the same rate as singletons until how many weeks?a .11 0 to 1 3 0 cal or i es p er k g. c o n j o i n e d t w i n s b . Which nursing action should be included in the baby's plan of care toprevent retinopathy of prematurity?a. 30 to 32 w eek s d. A m n i o c e n t e s i s b.H y dr al az i ne (A pr es ol i n e ) c .An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.Hy pertensionc . and retractions. tachypnea. Which of the following is normal newborn calorie intake?a. Anintradermal injection of purified protein derivative (PPD) of the tuberculin bacilli isgiven.Acetaminophen (Tylenol) for pain 93. I .c. .A flat circumcised area under 10 mm in diameter appears in 6 to 12hours.Cover his eyes while receiving oxygen.b. N a l o x o n e ( N a r c a n ) d. intubated. D i e t b .b. U l t r a s o u n d 89. cyanosis.30 to 40 calories per lb of body weight. di am ni ot i c m on o ch or i oni c t w i n d.H um i d i fy t h e o xy g en .95. malaise.A flat circumcised area over 10 mm in diameter appears in 48 to 72hours.Decreased inspiratory capacityd. Marlyn is screened for tuberculosis during her first prenatal visit.An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. Which of the following classifications applies to monozygotic twins for whomthe cleavage of the fertilized ovum occurs more than 13 days after fertilization?a .A nti h yp er t e n si v e a g ent s b . Which of the following procedures is usually performedto diagnose placenta previa?a . Aggressive management of a sickle cell crisis includeswhich of the following measures?a. A t l eas t 2 m l p er f ee di n g d .E xt er n al fet al m oni t or i n g d . unilateral flank pain.38 to 40 w e e k s 87.c .Keep her body temperature low. f l u i d s d. Dianne.di am ni ot i c d i ch or i oni c twi ns c .monoamniotic monochorionic twins88.Decreased oxygen consumption90. Cammile with sickle cell anemia has an increased risk for having a sickle cellcrisis during pregnancy. Nurse Arnold knows that the following changes in respiratory functioningduring pregnancy is considered normal:a .Rho (D) immune globulin (RhoGAM)94.18 to 22 weeksc.d. nausea.Monitor partial pressure of oxygen (Pao2) levels. She is considered to have a positive test for which of the following results?a. 85.d . and placed on aventilator.Seizure92. Tyra experienced painless vaginal bleeding has just been diagnosed ashaving a placenta previa.9 0 t o 100 c al or i es p er k g 86.grunting. Emily has gestational diabetes and it is usually managed by which of thefollowing therapy?a .c.I n cr e as e d t i da l vol um eb .Lo n ga cti n g i n sul i n c .Oral hypoglycemic drug and insulin91. nasal flaring.I n cr ea se d e xp i r at or y v ol u me c. O r a l h y p o g l y c e m i c d. 1 6 t o 1 8 weeksb.D igital or speculum examinationc . H y p o m a g n e s e m i a d.Calcium gluconate (Kalcinate)b . D i u r e t i c agentsc . Which of the following drugs is the antidote for magnesium toxicity?a. H e m o r r h a g e b. V . She'sdiagnosed with respiratory distress syndrome. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?a .

U t e r i n e a t o n y c.Solid formedc. and check for hemorrhage.L et har g y 2 da ys a ft er b i r t h.97. stimulatingmaternal antibodies.d. b l o o d y d . has just completed a difficult.In evaluating the effect of nitroglycerin. Whenassessing the neonate.Rh-negative maternal blood crosses into fetal blood. U t e r i n e inversionb .B a ct er i al v agi n osi s c.andcostovertebral angle tenderness. What are the first nursing actions of the nurse?a. 2 w e e k s postpartum. Which of the following diagnoses is most likely?a. c. check pupils.Increasing contractility and slowing heart rate.Decreasing contractility and oxygen . circulation.Rh-positive fetal blood crosses into maternal blood. Maureen. S t a n d i n g p o s i t i o n 98.d.Pyelonephritisd.A flattened nose.A male client is admitted to the emergency department following anaccident. the nurse John advises a client to assumecertain positions and avoid others. and thin lips.Check respiration.c.Urina ry tract infection (UTI)96. stimulating fetalantibodies. age 20.Uterine discomfort and left homonymous hemianopsia?a .W h er e t h e c l i en t l i k e 3. b. Where would nurse Kristine place the call light for a male client with aright-sided brain attack and check circulation. L a t e r a l positionb.O n t h e c l i en t ’ s l ef t si de c .O n t he c l i en t ’ s r i g ht si de b . Which position may cause maternalhypotension and fetal hypoxia?a . G r e e n liquidb.Irritability and poor sucking. a primigravida client.c.b . Her labor was unusually long and requiredoxytocin (Pitocin) augmentation.c.Assess level of consciousness and circulation.Rh-negative fetal blood crosses into maternal blood.Congenital defects such as limb anomalies.d.4. small eyes.Uterine involutiond.Nurse Michelle should know that the drainage is normal 4 days after asigmoid colostomy when the stool is:a .b. S e m i f o r m e d 2.Check respirations. Nurse Arthur should know that itreduces preload and relieves angina by:a. Rh isoimmunization in a pregnant client develops during which of thefollowing conditions?a. stimulatingmaternal antibodies. TEST III . the nurse Lhynnette expects to find:a . The nurse who's caring for her should stay alertfor:a .Di r e ct l y i n fr o nt o f t he cl i e nt d. To promote comfort during labor.Increasing AV conduction and heart rate. stimulating fetalantibodies. 7 th to 9 th day postpartum.forceps-assisted delivery of twins. Celeste who used heroin during her pregnancy delivers a neonate.100.Squatting positionc .c.d.A sy mpt om at i c b a ct er i ur i ab .Rhpositive maternal blood crosses into fetal blood. End of 6 th week postpartum.b.Loose. S u p i n e position d . stabilize spine.Care of Clients with Physiologic and Psychosocial Alterations 1.When the lochia changes to alba. neurological response. The uterus returns to the pelvic cavity in which of the following time frames? a.99.b.Align the spine.

B r o n chi al p n eu mo ni a c. He’stachypneic and afebrile and has a respiratory rate of 36 breaths/minute and hasa nonproductive cough.Blood pressure is decreased from 160/90 to 110/70.A dmi ni st er t w o q u i ck bl o ws.Make sure that the client takes food and medications at prescribedintervals.The client is oriented when aroused from sleep.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.V.C h est a nd l ow er b a ck pa i n b. E m p h y s e m a 14.Continue treatment as ordered.9. Form this history.After the ileostomy begin to function.d.The client refuses dinner because of anorexia.b .b . If action isn’t taken quickly. the client mayhave which of the following conditions?a . it will be important that the nurseimmediately position the client in:a. The partial thromboplastin time(PTT) is 68 seconds.c.d.Expect the warfarin to increase the PTT.He mo pt ysi s a n d D ys p nea d.c.On the back. A c u t e a s t h m a b . Cruz. Marichu was given morphine sulfate for pain.Call for help and note the time. and hemoptysisc. c.Chills. when should the drainage appliance beapplied to the stoma?a.5.b .Fever and c h i l l s c . night sweats.Fever of more than 104°F (40° C) and nausead . to prevent obstruction of airway by tongue.8. A male client has active tuberculosis (TB). and hasbeen receiving heparin I.On the side. He recently had a cold.24 hours later. The nurse should: a. Which is the nurse next action?a. with knees flexed 15 degrees. because the level is lower than normal.H ea da c h e an d p h ot o p ho bi a 13.Altered mental status and dehydration b. she might havewhich of the .Increase the dosage. and check the pulse.d. with the head turned to the side. C l e a r t h e a i r w a y c.b. F l a t o n b a c k .Chronic obstructive pulmonary disease (COPD)d .V. with an occasional skipped beat.A client undergone spinal anesthetic. 80 years old is diagnosed with pneumonia.10.When the client is able to begin selfcare procedures. and goes back tosleep immediately.7. Which of thefollowing symptoms may appear first?a. 6.Pulse is increased from 87 to 95.I n th e o pe r ati n g r o om . What should Nurse Carla do?a. Mark.A client undergone ileostomy. Which of the following symptomswill be exhibit?a . which assessment data suggest increasing intracranialpressure?a.Flat on the stomach. for 2 days.Monitor vital signs every 2 hours. c.b. She is sleeping and her respiratory rate is 4 breaths/minute.consumption.Provide milk every 2 to 3 hours.c. infusion of heparin and notify the physician.d. a 7-yearold client is brought to the emergency department. fever.Nurse Monett is caring for a client recovering from gastro-intestinalbleeding.Mrs.Pleuritic chest pain and cough12.d .While monitoring a male client several hours after a motor vehicleaccident.d.11.b.Give two sharp thumps to the precordium. when edema has subsided.d.Decreasing venous return through vasodilation.A male client was on warfarin (Coumadin) before admission.Plan care so the client can receive 8 hours of uninterrupted sleepeach night.Stop the I.

K e ep r o om s br i g ht l y l i t . In cr ease hi s a ct i vi t y l e vel . F i b r o c y s t i c m a s s e s 21.b. C a n c e r o u s l u m p s b. b .following reactions?a .Loss of e s t r o g e n c.Increased elastic recoil of the lungsb. catheter.Changes from previous examinations. Physicalexamination reveals shallow respirations but no sign of respiratory distress.17.Wake u p o n h i s o w n 15. Nurse Greta must logroll a clientfollowing a:a .23. S h a v i n g t h e a r e a c . the nurse should encourage the client to:a .Avoiding straining during bowel movement or bending at the waist.w h en s ex ual a ct i vi t y .d. d. sweating. Thenurse should treat excess hair at the site by:a . 18. 22. R ep or t i n c i d e nts o f d i ar r he a. F o l l o w a r e g u l a r d i e t . A 55-year old client underwent cataract removal with intraocular lens implant.d . C y s t e c t o m y . The nurse shouldexplain that the purpose of performing the examination is to discover:a . To decreasethe risk of atherosclerosis.Hemorrhoidect o m y d . D o w a g e r ’ s h u m p 20. the nurse should include information about which major complication:a . De cr ease d r esi du al v ol u me d .Increased number of functional capillaries in the alveolic.Monitor the client for signs of restlessness.Encourage the client to be active to prevent constipation.D e cr e as ed vi t al c a pa ci t y 16.A voi d foo d s h i gh i n vi ta mi n K c.V. These instructions shouldinclude which of the following?a. A 77-yearold male client is admitted for elective knee surgery. Nurse Ron is caring for a male client taking an anticoagulant.25 kg). Tak e as pi r i n to p ai n r el i e f.19.25.A vo i d fo c usi n g on h i s w ei ght .Areas of thickness or fullnessc.Increase in intracranial pressure (ICP). Nurse Michelle is caring for an elderly female with osteoporosis. B o n e f r a c t u r e b. The nurseshould teach the client to:a.Nurse Oliver is giving the client discharge instructions. and excessiveweight loss during thyroid replacement therapy.Removing the hair with a depilatory. N eg ati v e c al ci um b al a n ce d . 24.C l i p pi n g th e h ai r i n t he ar ea d. Nurse John is caring for a male client receiving lidocaine I. S e i z u r e d. d. Nurse Kris is teaching a client with history of atherosclerosis. Which factor isthe most relevant to administration of this medication?a. Whenteaching the client. A s t h m a a t t a c k b.b. When caring for a female client who is being treated for hyperthyroidism.Respiratory arrestc . L a m i n e c t o m y b . it isimportant to:a.Which of the following is a normal physiologic change related to aging?a. Le avi ng t h e ha i r i nt a ct b .d.Decrease in arterial oxygen saturation (SaO2) when measured with apulse oximeter.Continue leading a high-stress lifestyle. Nurse Lhynnette is preparing a site for the insertion of an I. c . George should be taught about testicular examinations during:a. b. T h o r a c o t o m y c.d.Presence of premature ventricular contractions (PVCs) on a cardiacmonitor. Nurse Len is teaching a group of women to perform BSE.Use a straight razor when shaving.Lie on your abdomen when in bedc .c.Balance the client’s periods of activity and rest.V. Nurse Greta is working on a surgical floor.Avoid lifting objects weighing more than 5 lb (2.b.Increase in systemic blood pressure c.Provide extra blankets and clothing to keep the client warm.

d. deep breathing and irregular breathing without pauses.Clean the cl ient’s mouth with hydrogen peroxide.Crackles have replaced wheezes.c.28. 34.30. Nurse Audrey is caring for a client who has suffered a severecerebrovascular accident. the client begins choking on hislunch. F i n e cracklesc.35.Stand him up and perform the abdominal thrust maneuver from behind.The airways are so swollen that no air cannot get through. During routine assessment.Lay him down.d.T h e swe l l i ng ha s d e cr ea se d . absent breath sounds. Mike with epilepsy is having a seizure. A male client undergone a colon resection.c. Nurse Ron is taking a health history of an 84 year old client.b.c . Cheyne-strokes respirations are:a.c. L eav e h i m t o g e t assi st a n ce d. He’s being hydrated with L. A 77year-old male client is admitted with a diagnosis of dehydration andchange in mental status. Nurse Krina should:a. 26.Coarse cracklesd. Theclient stops wheezing and breath sounds aren’t audible. When performing oral care on a comatose client. and hold downhis arms. Whichinformation will be most useful to the nurse for planning care?a. fluids. Nurse Maureen is talking to a male client. tracheal shift.d.Place the client on his back remove dangerous objects. B e f o r e a g e 2 0 . thenurse should:a. T r a c h e a l b .Stay with him but not intervene at this time. remove dangerous objects.d . b.c.Brush the teeth with client lying supine.c.Rapid.Apply lemon glycerin to the client’s lips at least every 2 hours. and protect hishead.Shallow breathing with an increased respiratory rate. and perform the abdominal thrustmaneuver. The reason for thischange is that:a . Fam i l y h i st or y of d i s eas es . He’s coughing forcefully.Place a salinesoaked sterile dressing on the wound.P ul l t he d ehi s ce n ce cl ose d .Rapid. After insertion of a cheat tube for a pneumothorax.V.Place the client in a side lying position.Place the client on his side. d. In f ec ti o n o f t h e l un g . remove dangerous objects. wounddehiscence with evisceration occurs. with the head of the bedlowered.Place the client on his side.Friction r u b s 29. b. Nurse Amanda suspects a tension pneumothorax has occurred. The nurse should a.b. While turning him. a client becomeshypotensive with neck vein distention. anddiaphoresis. The breath soundscommonly auscultated in clients with heart failure are:a .After age 4 0 d .General health for the last 10 years. and insert abite block. During the active seizure phase. A f t e r a g e 69c. d .Excessive water in the water-seal chamber d. 27.31. When the nursetakes his vital signs.Excessive chest tube drainage32. C a l l t h e p h y s i c i a n b.c . the nurse notices Cheyne-Strokes respirations.Current health promotion activities. she notes he has a fever of 103°F .b.b.33. straddle ar ts b . remove dangerous objects. and insert abite block. Tak e a b l o o d p r e ssur e a nd p ul s e.A progressively deeper breaths followed by shallower breaths withapneic periods b. T h e a t t a c k i s o v e r . deep breathing with abrupt pauses between each breath. Nurse Trish first response is to:a . Nurse Bea is assessing a male client with heart failure. M a r i t a l s t a t u s .What cause of tension pneumothorax should the nurse check for?a.Kinked or obstructed chest tubec.Place the client o his back. The nurse is caring for Kenneth experiencing an acute asthma attack.

c.Are not responsible for the anemia.The patient is under local anesthesia during the procedureb. The nurse suspects this clientmay have which of the following conditions?a. P n e u m o n i a d .The aspirated bone marrow is mixed with heparin.E l ev at e d t hr o mb o cy t e co u nt s 44.To determine the extent of lesionsd.adr e ner g i c b l o ck er s b . Vasquez 56year-old client with a 40-year history of smoking one to twopacks of cigarettes per day has a chronic cough producing thick sputum.A 16-year-old female high school studentb. Mr. Kennedy with acute asthma showing inspiratory and expiratory wheezes anda decreased forced expiratory volume should be treated with which of thefollowing classes of medication right away?a .Adult respiratory distress syndrome (ARDS)b . Virgie with a positive Mantoux test result will be sent for a chest X-ray.Abnormal blast cells in the bone marrowd.4°C) a coughproducing yellow sputum and pleuritic chest pain. During routine care.To determine if a repeat skin test is neededc.Uses nutrients from other cellsd. age 46 is admitted to the hospital with diagnosis of ChronicLymphocytic Leukemia. he mostlikely has which of the following conditions?a. Based on this information.c.y ear .P r e par e ox yg e n tr eat me nt d .The recipient receives cyclophosphamide (Cytoxan) for 4 consecutivedays before the procedure. The nurse immediatelynotifies the physician. A s t h m a c . L e u k o c y t o s i s c. Nurse Oliver is working in a out patient clinic. and asks her to prepare .Which statement about bone marrow transplantation is not correct?a.Have an abnormally short life span of cells. Diagnostic assessment of Francis would probably not reveal:a. Francis becomes disoriented and complainsof frequent headaches.40. B r o n c h o d i l a t o r sc. Francis asks the nurse. E m p h y s e m a Situation: Francis. Six hours later. C a l l t h e p h y s i c i a n b. Which of the following clients entering theclinic today most likely to have TB?a. He has been alerted that thereis an outbreak of tuberculosis (TB). a 57-year-old client with acute arterial occlusion of the left legundergoes an emergency embolectomy.A 43-yesr-old homeless man with a history of alcoholismd. R a i s e t h e s i d e r a i l s 42.43. The nurse in-charge first action would be:a .Adult respiratory distress syndrome (ARDS)b .T o c o n fi r m t he di a g nosi s b.(39. The treatment for patients with leukemia is bone marrow transplantation. Robert.peripheral edema and cyanotic nail beds. Cr ow d r e d bl o o d c e l l s b.The aspiration site is the posterior or anterior iliac crest.d.Inhaled steroidsd . T u b e r c u l o s i s 36.41.Predominance of lymhoblastsb .A 33year-old day-care worker c. O r a l s t e r o i d s 39.Document the patient’s status in his charts. After several days of admission.ol d b u si n ess ma n 37. the nurse isn’t able toobtain pulses in his left foot using Doppler ultrasound.B eta .To determine if this is a primary or secondary infection38. C hr o n i c o bstr u cti v e b r o n chi ti s d .c. My o car di al i nf ar c ti o n ( MI ) c . ―How can I be anemic if thisdisease causes increased my white blood cell production?‖ The nurse inchargebest response would be that the increased number of white blood cells (WBC) is: a .A 54 . Thenurse is aware that which of the following reasons this is done?a .

heparind. " c. and a respiratory rate of 22 breaths/minute. B e n z o d i a z e p i n e s 47.Which type of cancer causes the most deaths in women?a . She reports no history of cardiac disorders.Can't assess tumor or regional lymph nodes and no evidence of metastasisd.No evidence of primary tumor.Carcinoma in situ. which of the following clients should the on-dutynurse assess first?a.Opioidsc. "b. Breath sounds are clear and therespiratory rate is 26 breaths/minutes.Mobile mass that is soft and easily delineatedd. and ascending degrees of distant metastasis50. A 35-year-old client with vaginal cancer asks the nurse. no demonstrable metastasis of the regional lymphnodes.Lun g cancer c.Explain the risks of not having the surgeryb. " 51.the client for surgery.b. What does this classification mean?a. Honey. " K ee p t he st om a dr y ."Have a family member perform stoma care initially until you get usedto the procedure. a 23-year old client complains of substernal chest pain and statesthat her heart feels like ―it’s racing out of the chest‖. the nurse should include whichinstruction?a. As the nurseenters the client’s room to prepare him. A 37-year-old client with uterine cancer asks the nurse. dilitiazem (Cardizem)46. Whichassessment finding would strongly suggest that this client's lump is cancerous?a. he states that he won’t have any moresurgery. andno evidence of distant metastasisb.The 58-year-old client who was admitted 2 days ago with heart failure. The biopsy reportclassifies the lesion according to the TNM staging system as follows: TIS. C h e m otherapyc .The 62-yearold client who was admitted 1 day ago withthrombophlebitis and is receiving L. S u r g e r y b . "What is the usualtreatment for this type of cancer?" Which treatment should the nurse name?a . "Which is the mostcommon type of cancer in women?" The nurse replies that it's breast cancer. Cristina undergoes a biopsy of a suspicious lesion. I m m u n o t h e r a p y 49.Eversion of the right nipple and mobile massb.Notifying the nursing supervisor d. and a ―do not resuscitate‖ order c.M0.V. When teachingthe client how to care for the neck stoma."d . Which of the following drugs should thenurse question the client about using?a .Nonmobile mass with irregular edgesc. Which of the following is the best initial response by the nurse?a. N0. bloodpressure of 78/50 mm Hg.blood pressure of 126/76 mm Hg.V.Notifying the physician immediatelyc. no abnormal regional lymph nodes. Antonio with . R a d i a t i o n d .Recording the client’s refusal in the nurses’ notes45. Lydia undergoes a laryngectomy to treat laryngeal cancer. The nurse attaches her to a cardiac monitor and notes sinustachycardia with a rate of 136beats/minutes.Brain c a n c e r d . " Ke ep t he st oma moi s t . " Ke e p t he st oma un c ov er e d .Carcinoma in situ.Cocain e d . During the endorsement.Nonpalpable right axillary lymph nodes48. C o l on a nd r e ct al ca n cer 52. A 51-year-old female client tells the nurse in-charge that she has found apainless lump in her right breast during her monthly self-examination.The 75-year-old client who was admitted 1 hour ago with newonsetatrial fibrillation and is receiving L. no abnormal regional lymph nodes. B a r b i t u r a t e s b.The 89-year-old client with end-stage right-sided heart failure. and noevidence of distant metastasisc. B r e a s t cancer b .

b.c.T h e cl i e nt ask s q u est i o ns .59.b.Carcinoembryoni c antigen (CEA)c . Joint painb.To avoid fractures. usually in the feet andlegs.The recommended daily allowance of calcium may be found in a widevariety of foods. Joint flexion of less than 50%d. During a breast examination."c. which is used to determine protein levels. both onthe affected side.Which of the following teaching points is correct?a."Avoid drinking liquids until the gag reflex returns. Th e cl i ent l i es st i l l .d . the nurse should note:a. weight loss.protein serum antigen. partial eyelid ptosis. When assessing for signs and symptoms of this syndrome. Bloody discharge from the nippled. Which finding is acontraindication?a."d. C o l o n c."Notify a nurse if you experience blood in your urine.The client wears a watch and wedding band. the nurse reviews the assessmentfindings for contraindications for this procedure. which is a bacteria that causespneumonia.miosis.W hi t e bl oo d c e l l s ( WB C s) 58. L i v e r b .Obtaining an X-ray of the bones every 3 years is recommended todetect bone loss.c.Obtaining the recommended daily allowance of calcium requires takinga calcium supplement. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) toconfirm or rule out a spinal cord lesion. which finding most strongly suggests that theLuz has breast cancer?a.Papanicolaou -specific antigen.d. Joint deformityc.pneumococcal strep antigen. dyspnea.arm and shoulder pain and atrophy of arm and hand muscles. and anhidrosis on the affected side of theface. Int er mi t t en t .b . and fever. freely movable masses that change with themenstrual cycle57. Tr au mat i c ar t hr i t i s c. round. S t o o l H e m a t e s t b. which is used to screen for cervicalcancer. Whichof the following is one of the most common metastasis sites for cancer cells?a . the client should avoid strenuous exercise. which of thefollowing would pose a threat to the client?a .chest pain. S e p t i c a r t h r i t i s b . Multiple firm.d."Avoid eating milk products for 24 hours.54.Reproductive t r a c t d . Mr. What is the most important postoperative instruction that nurse Kate mustgive a client who has just returned from the operating room after receiving asubarachnoid block?a.60. S i g m o i d o s c o p y d. Vic asks the nurse what PSA is.lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia.b.c. A female client with cancer is being evaluated for possible metastasis.d. Rodriguez is admitted with severe pain in the knees."55. Joint stiffness 61. A male client suspected of having colorectal cancer will require whichdiagnostic study to confirm the diagnosis?a .b. cough. c. The nurse should reply that it stands for:a."Remain supine for the time specified by the physician. During the MRI scan.A bdominal computed tomography (CT) scan 56. A fixed nodular mass with dimpling of the overlying skinc. hoar se n ess a nd d y sp ha gi a."b.The client hears thumping sounds.prostate-specific antigen. Which form of arthritis is characterized by urate deposits and joint pain. and occurs primarily in men over age 30?a . which is used to screen for prostate cancer. Before Jacob undergoes arthroscopy. Nurse Cecile is teaching a female client about preventing osteoporosis. 53. Slight asymmetry of the breasts.

Osteoarthritis has dislocations and subluxations. Mrs.They contain exudate and provide a moist wound environment. Which of the following conditions may cause swelling after a stroke?a. 30 ml/hour c.500 unit/hour is ordered for a 64year-old client withstroke in evolution. a wet-to-dry dressing change every shift. How many milliliters per hour should be given?a. Mr. f u r o semide ( L a s i x ) c . 15 ml/hour b. c o l c h i c i n e s d. 50 ml/hour 63.It appears on the dorsolateral aspect of the interphalangeal joint. 10 U regular insulin and 20 U NPH.b.d. the doctor orders bed rest. There is no 70/30 insulin lcium gluconate (Kalcinate)69.Hypoalbuminemia due to protein escaping from an inflamedglomerulus64. A 76-yearold male client had a thromboembolic right stroke.It a p pear s o nl y i n me n b.000 units of heparin in 500 ml of saline solution. the nurse may givethe client:a. Cruz uses a cane for assistance in walking.It appears on the proximal interphalangeal jointd. A d r enal m e d u l l a d .Osteoarthritis is a systemic disease.Elbow contracture secondary to spasticityb.Deep vein thrombosis (DVT) due to immobility of the ipsilateral sided.c. Which of the followingstatements is true about a cane or other assistive devices? a. Nurse Len should expect to administer which medication to a client withgout?a . Nurse Zeny is caring for a client in acute addisonian crisis. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).Osteoarthritis is a localized disease rheumatoid arthritis is systemicc.The cane should be used on the affected sidec. A heparin infusion at 1. rheumatoid arthritis is localizedd. A d r e n a l cortexb . rheumatoid arthritis isn’tb. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30insulin.b. rheumatoid arthritisdoesn’t66.They prevent the entrance of microorganisms and minimize wounddiscomfort.They debride the wound and promote healing by secondary intention. 20 U regular insulin and 10 U NPH. Which laboratorydata would the nurse expect to find?a . Why are wet-to-dry dressings used for this client?a. a s p i r i n b . and blood glucose monitoring before mealsand bedtime. This diagnosis indicates that the client's hypertension iscaused by excessive hormone secretion from which of the following glands?a . 45 ml/hour d.They protect the wound from mechanical trauma and promote healing. his left arm isswollen. For a diabetic male client with a foot ulcer. P a n c r e a s c . 21 U regular insulin and 9 U NPH.68. Which of the followingstatement is correct about this deformity?a . Domingo with a history of hypertension is diagnosed with primaryhyperaldosteronism.A client with osteoarthritis should be encouraged to ambulate withoutthe t hr i t i s d . H y p e r k a l e m i a .A walker is a better choice than a cane. The infusion contains 25.It appears on the distal interphalangeal jointc.71.65.Loss of muscle contraction decreasing venous returnc. G o u t y a r t h r i t i s 62.The cane should be used on the unaffected sided.b.Osteoarthritis is gender-specific.d. As a substitution.c. Which of the following statements explains the main difference betweenrheumatoid arthritis and osteoarthritis?a. Heberden’s nodes are a common sign of osteoarthritis. P a r a t h y r o i d 70.

Infusing I. the nurse notifies the surgeon p m 75. a n d a n or e xi a d. Which set of ."d.Carcinoembryonic antigen level78. c ."Sterilize all plates and utensils in boiling water. fluids rapidly as orderedb.Dyspnea. Which laboratory test value is elevated in clients who smoke and can't beused as a general indicator of cancer?a . the clientreports numbness and tingling of the mouth and fingertips. Na use a. Todetermine the effectiveness of the client's efforts. H y p o c a l c e m i a b . d. When questioned. In teaching a female client who is HIVpositive about pregnancy."Avoid sharing such articles as toothbrushes and razors. Hyponatremiac. Suspecting a lifethreatening electrolyte disturbance.Glucocorticoids and androgensb.b.s er um f r u ct osa mi n e l ev el . tachycardia. Francis with anemia has been admitted to the medical-surgical unit. b .f asti n g bl ood g l uc os e l e vel .A ci d p ho sp h at as e l ev el b ."b.Hyperk alemia d . When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home.V. A client is admitted for treatment of the syndrome of inappropriate antidiuretichormone (SIADH). At what time would the nurse expect the client to be mostat risk for a hypoglycemic reaction?a . Which nursing intervention is appropriate?a."b. 1 0 : 0 0 amb ."c.Mineralocorticoi ds and catecholaminesd. 4 : 0 0 p m d. H y p e r m a g n e s e m i a 77. "I'm planning on starting on birth control pills.S er um cal ci t on i n l ev el c. an d j a u nd i c e 79."80."Not everyone who has the virus gives birth to a baby who has thevirus.10:00 producing which substances?a.m. the nursewould know more teaching is necessary when the client says:a."81. the nurse should check:a ."d.V. Whichassessment findings are characteristic of iron-deficiency anemia?a.Catecholamines and epinephrinec. v omi t i n g ."Avoid eating foods from serving dishes shared by other familymembers. A l k a l i n e p h os ph atas e l ev el d. The adrenal cortex is responsible for immediately. R e s t r i c t i n g f l u i d s d. On the third day after a partial thyroidectomy. and pallor c ."Put on disposable gloves before bathing. Nurse Marie is caring for a 32-year-old client admitted with perniciousanemia. H y p e r n a t r e m i a d . N o o n c .The baby can get the virus from my placenta. the nurse should be sure to include which instruction?a.Nights sweats. fluids as ordered73.Which electrolyte disturbance most commonly follows thyroid surgery?a .Administering glucosecontaining I. r a sh .Reduced blood urea nitrogen (BUN)c . Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to adiabetic client at 7 a. H y p e r g l y c e m i a 72. It ch i n g .glycosylated hemoglobin level.74. A female client tells nurse Nikki that she has been working hard for the last 3months to control her type 2 diabetes mellitus with diet and exercise. ur i n e gl u c os e l ev el . weight loss."c.Norepinephr ine and epinephrine76. Proserfina exhibits muscletwitching and hyperirritability of the nervous system. and diarrheab."I'll need to have a C-section if I become pregnant and have a baby.Encouraging increased oral intakec .

and partial thromboplastin timeb.After recovering from the initial shock of the diagnosis.Page an anesthesiologist immediately and prepare to intubate theclient. w e i g h t g a i n . a client develops dyspnea andhypotension.84. and white blood . N e u t r o p h i l b . These include:a .V.c. After receiving a dose of penicillin. night sweats. bradycardia.enzyme-linked immunosuppressant assay (ELISA) test.b.fine motor t r e m o r s . and a sore tonguec.enzyme-linked immunosorbent assay (ELISA). A male client seeks medical evaluation for fatigue. d. prothrombin time.Sore tongue. When teaching the client about aspirin.electrolyte panel and hemogram. What does this test seek to identify?a. 88. and anorexia 82.d .Insert an indwelling urinary catheter and begin to infuse I. What should the nurse do first?a.flat plate X-ray of the abdomen.Potential hepatic dysfunction indicated by decreased blood ureanitrogen (BUN) and creatinine levelsb. In an individual with Sjögren's syndrome. Nurse Celestina suspects the client is experiencing anaphylacticshock. During chemotherapy for lymphocytic leukemia.Pallor. the nurse discussesadverse reactions to prolonged aspirin therapy. tachycardia.87. bi l ater al h e ar i n g l oss . Mr. M o n o c y t e d. the nurse should take note of what assessment parameters?a. double vision. To confirm that the client has been infected with thehuman immunodeficiency virus (HIV).Administer the antidote for penicillin.Ly m p h o c y t e 85.c.findings should the nurse expect when assessing theclient?a.E-rosette immunofluorescence.Pallor.Low levels of urine constituents normally excreted in the urinec. B a s o p h i l c .d.quanti fication of T- lymphocytes. While monitoring a client for the development of disseminated intravascular coagulation (DIC). and reduced pulse r h yt h mi a ma na gem e nt .Angina. b.b. as prescribed. el e ctr ol yte b al a n ce . blood glucose levels. stool for Clostridium difficile test. and "horse barn" smelling diarrhea. and prepare to intubate theclient if necessary.Administer epinephrine.We st er n b l o t t e st w i t h E L ISA .Platelet count.b. It would be most important for thenurse to advise the physician to order:a. Marquez with rheumatoid arthritis is about to begin aspirin therapy toreduce inflammation.Electrolyte imbalance that could affect the blood's ability to coagulateproperly89. Mathew develops abdominalpain. and continue tomonitor the client's vital signs. When teaching the client about the immune system. fever. A complete blood count is commonly performed before a Joe goes intosurgery. dyspnea. d. c . 86. nursing care should focus on:a. mo i st ur e r epl a cem e nt .r es pi r at or y a ci d osi s . the client expresses adesire to learn as much as possible about HIV and acquired immunodeficiencysyndrome (AIDS). fluids asordered. c.83. c .Platelet count. as prescribed. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). and weight gaind.b . and a 20-lbweight loss in 6 weeks.n utr i ti o nal s u ppl em en tati on .d. the nurse expects the physician to order:a. the nursestates that adaptive immunity is provided by which type of white blood cell?a .Abnormally low hematocrit (HCT) and hemoglobin (Hb) levelsd.

and potassium levelsd.d.A 35-year-old admitted three hours ago with a gunshot wound. The client isoccasionally confused and her gait is often unsteady.Straw b e r r i e s 91. client complaints of chills.b.b.Blood pressure 138/82.The client holds the cane with his right hand. Which of the followingactions should the nurse take first?a. C a r r o t s c . respirations 16.d.c. if demonstrated by the client to the nurse.The client is drowsy and complains of sore throat.‖b. and platelet count90.95. moves the cane forwardfollowed by the right leg. ―My arms and legs are itching.The client supports his head and neck when turning his head to theright. Nurse John is caring for clients in the outpatient clinic.Ask the .c. oral temperature 99 degreesFahrenheit. calcium levels.‖92. 1. moves the can forwardfollowed by the right leg.b.I ns er t a F ol e y c at h eter 96.5 cmarea of dark drainage noted on the dressing. The nurse would be most concerned if which of thefollowing was observed?a.Use comfort measures and pillows to position the client.Administer Demerol 50 mg IM q 4 hours and PRN.b. if taken by the nurse. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief.A 62year-old who had an abdominalperineal resection three daysago. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease.A client with hepatitis A who states.93.c.Assess for a bruit and a thrill.Thrombin time.c. moves the cane forwardfollowed by his left leg. and then moves the right leg.Position the client on the left side.d. ―I am so nauseousthat I can’t eat.The client spontaneously flexes his wrist when the blood pressure isobtained. ―I have a funny feeling inmy right leg. Nurse Sarah is caring for clients on the surgical floor and has just receivedreport from the previous shift. and then moves the left leg.A 59-yearold with a collapsed lung due to an accident.Warm the dialysate solution.indicates that the teaching was effective?a. Nurse Tina prepares a client for peritoneal dialysis.c.Encourage the client to change positions frequently in bed. When taking a dietary history from a newly admitted female client.cell (WBC) countc.b. An elderly client is admitted to the nursing home setting. Which of the followingactions.The client holds the cane with his left hand. Nurse Lenshould remember that which of the following foods is a common allergen?a .A 43-year-old who had a mastectomy two days ago. ―I am having troublesleeping. O r a n g e d.A client with rheumatoid arthritis who states. B r e a d b .A client with cast on the right leg who states. no drainagenoted in the previous eight hours. Which of the followingphone calls should the nurse return first?a. Nurse Jannah teaches an elderly client with right-sided weakness how to usecane.Fibrinogen level.94. and then moves the left leg.The client holds the cane with his left hand. the nurse should take which of thefollowing actions?a. 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.‖c.d.d .‖ d.The client holds the cane with his right hand.A client with osteomyelitis of the spine who states. Which of the following behaviors. WBC. and then moves the right leg. moves the cane forwardfollowed by his left leg.Apply warmth to the abdomen with a heating pad. is most appropriate?a. Which of the following clients should the nurse seefirst?a.97.

Encourage the woman to ambulate in the halls twice a day.d. Nurse Ruby should monitor the client for the systemic sideeffect of:a .Increase the client’s oxygen flow rate. Hypertensiond . moves it forward 10 inches.Decrease the size and vascularity of the thyroid gland.Tracy is receiving combination chemotherapy for treatment of metastaticcarcinoma. P a i n b . W e i g h t c . what assessment would promptNurse Katrina to suspect organ rejection?a .Maintain the function of the parathyroid glands.Matilda.The client supports his weight on the walker while advancing it forward.Block the formation of thyroxine by the thyroid TEST IV .4.99. with recent colostomy expresses concern about the inability tocontrol the passage of .woman’s family to provide personal items such as photos or mementos. if demonstrated by the client.Suggest the woman eat her meals in the room with her roommate. H e m a t u r i a d.b.Select a room with a bed by the door so the woman can look down thehall. Type 2 diabetesd .Norma.b.then takes small steps while balancing on the walker. was diagnosed with type I diabetes. then takessmall steps forward while leaning on the walker. mildlyhypertensive male client with ureteral colic and hematuria is to decrease:a . 100. H y p e r t h y r o i d i s m 5 . auditory. with hyperthyroidism is to receive Lugol’s iodine solution before asubtotal thyroidectomy is performed. A male client with emphysema becomes restless and confused.Increased sensitivity to the side effects of medications. N y s t a g mus c.Hypertension c. and gustatory abilities. indicatesthat the nurse’s teaching was effective?a.Hy p e r t e n s i o n 3. d. A s c i t e s b .Decrease musculoskeletal function and mobility. Nurse Deric is supervising a group of elderly clients in a residential homesetting.Ricardo.The immediate objective of nursing care for an overweight.c. Nurse Evangeline teaches an elderly client how to use a standard aluminumwalker. S h o c k 2.d.b.Decreased visual. What stepshould nurse Jasmine take next?a.The client slowly pushes the walker forward 12 inches.Decrease the total basal metabolic rate. S u d d e n w e i g h t lossb .98. then takes small stepswhile holding onto the walker for balance. The nurse knows that the elderly are at greater risk of developingsensory deprivation for what reason?a.b.Pol ycythemia 6. The client slides the walker 18 inches forward.d. P o l y u r i a c.Assess the client’s potassium level.Leuk openi a d.c.Care of Clients with Physiologic and Psychosocial Alterations 1.Encourage the client to perform pursed lip breathing.b. Which of the following behaviors. The nurse is aware thatacute hypoglycemia also can develop in the client who is diagnosed with:a .c. and then takesseveral small steps forward.d.Randy has undergone kidney transplant.The client lifts the walker. The nurse is aware that thismedication is given gland. L i v e r diseaseb. to:a.Isolation from their families and familiar surroundings.c.Check the client’s temperature.c.

b.b. the physician orders for Mario2 liters of IV fluid to be administered q12 h.Instill a minimum of 1200 ml of irrigating solution to stimulateevacuation of the bowel. the nurse's highest priority of information would be: . Bleeding from earsd. 36 gtt/min10.Facilitate ventilation of the left lung. In the postanesthesia care unit Tonny is placed inFowler's position on either his right side or on his back.The nurse is ware that the most relevant knowledge about oxygenadministration to a male client with COPD isa. The nurse isaware that this position:a.‖d. Ri g ht u p per ar m a n d p eni s c. 18 gtt/minb.V.Blood gases are monitored using a pulse oximeter. the nurse wouldexpect to:a. An elevated temperature 12. b.d.Eliminate foods high in cellulose. take the pulse rate once a day.Insert the irrigating catheter deeper into the stoma if crampingoccurs during the procedure. Nurse Oliver should suggest that the clientplan to:a.Adhere to a bland diet prior to social events.14.9.Oxygen at 12L/min is given to maintain the hypoxic stimulus for breathing.Kristine is scheduled for a bronchoscopy.Oxygen is administered best using a non-rebreathing maskd.Tonny has undergoes a left thoracotomy and a partial pneumonectomy.d.Decrease fluid intake at meal times.gas.Administer large amounts of normal saline via I. When assessing theclient. The nurse should set the flow to provide:a. ―I should:a. a 45 year old construction engineer is brought to the hospitalunconscious after falling from a 2-story building. The drop factor of the tubing is10 gtt/ml.Terence suffered form burn injury.Hypoxia stimulates the central chemoreceptors in the medulla thatmakes the client breath.A dm i ni ster K a ye xal at e b.Chest tubes are inserted. May be allowed to use electrical appliancesc. Using the rule of nines. A depressed fontanelc. Nurse Sherry is teaching male client regarding his permanent artificialpacemaker.c.Equalize pressure in the pleural space. May engage in contact sports13.Avoid foods that in the past caused flatus.Lie on my left side while instilling the irrigating solution. Reactive pupilsb. 28 gtt/minc.Mario has burn injury. the nurse would be most concerned if the assessment revealed:a.‖b. The client is somewhatconfused and complains of nausea and muscle weakness. 32 gtt/mind. In cr eas e v eno us r et ur n 15.Right thigh and penisd .Keep the irrigating container less than 18 inches above the stoma. Re d u ce i n ci si o nal p ai n. As part of theprescribed therapy to correct this electrolyte imbalance.c.‖c.d .c.Patrick is in the oliguric phase of acute tubular necrosis and isexperiencing fluid and electrolyte imbalances. Have regular follow up cared. The nurse would evaluate that the instructions wereunderstood when the client states.Increase oral intake of cheese and milk. F a c e a n d n e c k b . After Forty48 hours. When teaching Kristine what toexpect afterward. and one-bottle waterseal drainage is institutedin the operating room. Herbert. Which information given by the nurse shows her knowledgedeficit about the artificial cardiac pacemaker?a. Re str i ct f oo d s h i gh i n pr ote i n c.‖8. U p p e r t r u n k 11. in the morning upon awakeningb.Nurse Ron begins to teach a male client how to perform colostomyirrigations. which has thelargest percent of burns?a .7.

b.5 mg/dl. After admittingthat she read her chart while the nurse was out of the room.c. 20. Thenurse is aware that the diagnostic test are consistent with CRF if the resultis:a. Why does the client require special positioning for this type of anesthesia?a.The kidneys are situated just above the adrenal glands. To pr e ve nt c o n fus i o n b . h y pokalemia.c.Increase in the number of normal cells in a normal arrangement ina tissue or an organ.S q uam ous ce l l c ar ci no ma b . h y p e r n a t r e m i a .b.Nurse Tristan is caring for a male client in acute renal failure.The most common treatment is metronidazole (Flagyl). X has just been diagnosed with condylomata acuminata (genitalwarts). What is the most common AIDS-related cancer?a .b.The kidneys lie between the 10th and 12th thoracic vertebrae. magnesium. which causes condylomataacuminata. and organization of differentiated cells. T o p r e v e n t s e i z u r e s c. she should have a Papanicolaou (Pap) smear annually. During a routine checkup. Katrina has an abnormal result on a Papanicolaou test.b.18.16.Uric acid analysis 3.c. b .Food and fluids will be withheld for at least 2 hours. When palpating the her kidneys. h y p e r c a l c e m i a .d.Alteration in the size.c.The average kidney is approximately 5 cm (2") long and 2 to 3 cm(¾" to 11/8") wide.hyperkale m i a .Replacement of one type of fully differentiated cell by another intissues where the second type normally isn't found. d. and calcium.c.Increased serum levels of potassium.d.b.To prevent cerebrospinal fluid (CSF) .Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6. The nurseshould expect hypertonic glucose.a. and sodiumbicarbonate to be used to treat:a . d . shape.Warm saline gargles will be done q 2h. Which definition should the nurse provide?a. 21. the nurse should keep which anatomical fact in mind?a. whichshould eradicate the problem within 7 to 10 days. insulin infusions.d. L e u k e m i a d. Katrina askswhat dysplasia means. Nurse Mariane assesses a male client withacquired immunodeficiency syndrome(AIDS)for signs and symptoms of cancer.d. What information is appropriate to tell this client?a. can't be transmitted during oral sex. and the anesthesiologist plansto use a spinal (subarachnoid) block during surgery. the nurse positions the client according to the anesthesiologist'sinstructions.Ricardo is scheduled for a prostatectomy.5 mg/dl and phenolsulfonphthalein (PSP)excretion 75%.Jestoni with chronic renal failure (CRF) is admitted to the urology unit.19.therefore.This condition puts her at a higher risk for cervical cancer.The potential for transmission to her sexual partner will beeliminated if condoms are used every time they have sexualintercourse.Coughing and deep-breathing exercises will be done q2h.Increased pH with decreased hydrogen ions.The human papillomavirus (HPV). K a p o s i ' s s a r c o m a 22.c.The left kidney usually is slightly higher than the right one. 17.Presence of completely undifferentiated tumor cells that don'tresemble cells of the tissues of their origin.M s. In the operatingroom.Only ice chips and cold liquids will be allowed initially. M u l t i p l e myelomac .Maritess was recently diagnosed with a genitourinary problem and isbeing examined in the emergency department.

Nurse Maria plans to administer dexamethasone cream to a female clientwho has dermatitis over the anterior chest. and downward strokes in the direction of hair growthd.b. Re d u ce t h e c l i en t' s fl ui d i ntak e. On what position should the nurseplace the head of the bed to obtain the most accurate reading of jugular vein distention?a . d .P al p at e t he ab do me n .Anthony suffers burns on the legs. Ca l c i um ch an n el b l o ck er c .A male client with inflammatory bowel disease undergoes an ileostomy. NurseCelia should:a .d. to enhance absorption.c .26.A male . H i g h F o w l e r ’ s b. To help the client avoid pressure ulcers. N i t r a t e s 31. even.c. b . N a r c o t i c s d .B et a .and third-degreeburns on the face.In s er t a r e ctal t ub e .This is a normal finding 1 day after surgery.Wilfredo with a recent history of rectal bleeding is being prepared for acolonoscopy.Ur i ne o ut pu t o f 2 0 ml / ho ur .Raised 30 degreesd. The first nursing action should be to:a. Ca l c i um ch an n el b l o ck er c .Perform passive range-of-motion (ROM) exercises.E l e vati n g th e fo ot o f t he be d c.In long.On the first day after surgery.T ur n h i m f r e q ue ntl y .Encourage the client to use a footboard. arms.An intestinal obstruction has occurred.B e t a a dr en er gi c b l o ck er s b. d.b. I n o t r o p i c a g e n t s 33.With an upward motion.A male client has jugular distention.Lying on the left side with knees bentc . Nurse Oliver notes that the client's stomaappears dusky. How should the nurse applythis topical agent?a. How should the nurse Patricia position the client for this testinitially? a. c.W hi t e p ul m on ar y s e cr e ti o ns .Blood supply to the stoma has been interrupted.The ostomy bag should be adjusted. C han g e t he c l i en t' s p osi ti o n.a dr e n er gi c b l o ck er s b. 29.To prevent cardiac arrhythmias23. 24. Which finding indicates a potentialproblem? a.P r on e wi t h t he t or s o e l e vat e d d. outward. D i u r e t i c s d .Performing shoulder range-of-motion exercises27. Mendoza who has suffered a cerebrovascular accident(CVA)is tooweak to move on his own. How should the nurse interpret this finding?a.6° F (38° C).A ppl yi n g k n e e s pl i nt s b . which nursing intervention helpsprevent contractures?a . 28. d.Rectal temperature of 100. to increase blood supply to the affectedareac. Partial pressure of arterial oxygen (PaO 2 ) value of 80 mm Hg.Raised 10 degreesc.Nurse Kate is aware that one of the following classes of medicationprotect the ischemic myocardium by blocking catecholamines andsympathetic nerve stimulation is:a .Supine p o s i t i o n 32. b.Lying on the right side with legs straightb. and upward strokes in the direction oppositehair growth30.Nurse Ron is assessing a client admitted with second.A us c ul t a t e b ow el s ou n ds.Hyperextending the client's palmsd. and chest. outward.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea.Bent over with hands touching the floor 25.leakaged.With a circular motion.c .b.In long.The nurse is aware that one of the following classes of medicationsmaximizes cardiac performance in clients with heart failure by increasingventricular contractility?a. Mr. even.

line and administer amiodarone (Cardarone).The CCU nurse gives a verbal report to the nurse on the telemetryunit before transferring the client to that unitb. a client’s blood pressure measures 126/80 mm Hg. oxygen. creatine kinase and lactate dehydrogenase levelsb.Prothrombin time. A decrease in plateletcount from 230. c. Which of the following actionswould breach the client confidentiality?a. testing for occult blood.Nurse Katrina determines that mean arterial pressure (MAP) is which of thefollowing?a . 4 6 m m H g b . 300 mgL.Electroencephalogram. V i t a m i n K 40.000 ul is noted?a .At the client’s request. partial thromboplastin time.Idi opathic thrombocytopemic purpura (ITP)c.Cardiac monitor. A u t o logousc. Methotrezated . A male client arriving in the emergency department is receivingcardiopulmonary resuscitation from paramedics who are giving ventilationsthrough an endotracheal (ET) tube that they placed in the client’s home.The emergency department nurse calls up the latestelectrocardiogram results to check the client’s progress. fibrinogen and fibrin splitproduct values.client has a reduced serum highdensity lipoprotein (HDL) leveland an elevated low-density lipoprotein (LDL) level.V.V. 9 5 H g d . During apause in compressions.d. A female client is scheduled to receive a heart valve replacement with aporcine valve. C o r t i c o s t e r o i d s c . the cardiac monitor shows narrow QRS complexes anda heart rate of beats/minute with a palpable pulse.Syngeneicd. A l l o g e n e i c b . complete blood count.36. Which of the followingactions shows . over 10 minutes. X e n o g e n e i c 41.Less than 30% of calories form fatc.V. Marco falls off his bicycle and injuries his ankle.000 ul to 5.Administer atropine. the CCU nurse updates the client’s wife onhis condition35. Which of the followingdietary modifications is not appropriate for this client?a . Which of the following actionsshould the nurse take first?a.The CCU nurse notifies the on-call physician about a change in theclient’s conditionc. Which of the following drugs would be ordered by the physician to improvethe platelet count in a male client with idiopathic thrombocytopenic purpura(ITP)?a .Electrocardiogram.d. 8 0 H g c .Heparin-associated thrombosis and thrombocytopenia (HATT)39.Check endotracheal tube placement. P a n c y t o p e n i a b. alkaline phosphatase and aspartate aminotransferaselevels.Start an L. Macario had coronary artery bypass graft (CABG) surgery 3 days ago.d. After cardiac surgery. Which of the following types of transplant is this?a . Which of the followingorder should the nurse Oliver anticipate?a.Less than 10% of calories from saturated fat34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2days ago with an acute myocardial infarction.Obtain an arterial blood gas (ABG) sample.c.Fi b er i ntak e o f 25 to 3 0 g d ai l y b.comprehensive serum metabolic panel. basic serum metabolic panel38. 9 0 m m m m m m H g 37.Cholesterol intake of less than 300 mg dailyd.A c et yl s al i c yl i c a ci d female client arrives at the emergency department with chest and stomachpain and a report of black tarry stool for several months. 1 mg L.b. Whichof the following conditions is suspected by the nurse when a (A SA ) b .Disseminated intravascular coagulation (DIC)d.

P e r i c a r d i t i s b . Stacy is discharged from the hospital following her chemotherapy treatments.Breath s o u n d s 45.Renal d y s f u n c t i o n d. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.the initial response to the injury in the extrinsic pathway?a . M u s c l e s p a s m c.Conversion of factors XII to factor XIIad. andunexplained weight loss over the past 3 months.d.Release of tissue thromboplastinc.More than 10 y e a r s 47. But try to cover up your feelings when you are with her or else she may be upset‖.d. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). drenching night sweats. L e s s t h a n 5 yearsb . R e l e a s e o f C a l c i u m b. E ss en ti al t hr o mb o cy to pe ni a d . S p l e n o m e g a l y d.―My physician should be called if Stacy is irritable and unhappy‖.c. I need to call the doctor‖. The nurse is aware that the following symptoms is most commonly an earlyindication of stage 1 Hodgkin’s disease?a . A male client with a gunshot wound requires an emergency bloodtransfusion.A Rhnegatived. 50.b. Physical examination reveals asingle enlarged supraclavicular lymph node. Francis with leukemia has neutropenia.Ho d g k i n ’ s d i s e a s e 49. 5 t o 7 yearsc .―I should contact the physician if Stacy has difficulty in sleeping‖. B o w e l soundsc.51.H ea r t s ounds d. Which of the following laboratoryfindings is most consistent with DIC?a . The nurse knows that neurologic complications of multiple myeloma (MM)usually involve which of the following body system?a .b.―Should Stacy have continued hair loss. P er si st e nt h y pot h er mi a 44.―Stacy looks very nice wearing a hat‖. L e u k e m i a d.Dr es sl er ’ s s y ndr om e b . Which of the following is the mostprobable diagnosis?a . just be glad that she is alive‖. L o w p l a t e l e t c o u n t b . I n f l u e n z a b .Which statement of Stacy’s mother indicated that she understands when she willcontact the physician?a.The best response for the nurse is:a.―I will call my doctor if Stacy has persistent vomiting and diarrhea‖.Conversion of factor VIII to factor VIIIa42.Low levels of fibrin degradation productsd . Nurse Patricia is aware that the average length of time from humanimmunodeficiency virus (HIV) infection to the development of acquiredimmunodeficiency syndrome (AIDS)?a . 1 0 y e a r s d. B r a i n b . A R h positivec. M yo car di a l i r r i t abi l i t y 46. Which blood type would be the safestfor him to receive?a . S i c kle cell anemiac . Which of the following functions mustfrequently assessed?a .O Rhpositive Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. N i ght s w e a t c . V on Wi l l e br a nd ’s d i s eas e 43. Instructions for a client with systemic lupus erythematosus (SLE) wouldinclude information about which of the following blood dyscrasias?a.―Yes it is upsetting.R e du c ed p r ot hr o mbi n ti m e 48.c.―You should not worry about her hair.E l ev at e d f i br i n og e n l ev el s c.―This is only . Mario comes to the clinic complaining of fever. A B R h positiveb . P o l y c y t h e m i a c . B l o o d pressureb . His blood type is AB negative.

b. Mr. Stacy has beginning stomatitis.Elevated serum aminotransferase60. The nurse bestaction would be:a. She has a decreased level of consciousness. she develops chest tightness and becomes short of breath andtachypneic. m m H g c .52.Adult respiratory distress syndrome (ARDS)b .Immediately discontinue the infusiond. Timothy’s arterial blood gas (ABG) results are as follows.Rinse mouth with Hydrogen Peroxide. A s t h m a a t t a c k b. E m p h y s e m a 55.Altered level of consciousnessc .Decreased red blood cell countb. Paco2 80mm Hg. every 2 hours. Norma has started a new drug for hypertension.16. Nurse Oliver wouldexpect the paco2 to be which of the following values?a .d. Gonzales regained consciousness.b.Decreased serum acid phosphate levelc.Apply an ice pack to the site. When Mr.Respiratory f a i l u r e d . To promote oral hygiene and comfort. Which clinical manifestationis most common with this condition?a.R h eum atoi d ar t hr i t i s Situation: Mr. HCO324mEq/L. To rule out cirrhosis of the liver : 59. Sao2 81%. when the IV is touched Stacy shouts in pain. Gonzales develops hepatic encephalopathy.53. An arterial blood gas value is obtained. followed by warm compress. Jose is in danger of respiratory arrest following the administration of anarcotic analgesic. 3 0 m m m m H g 57. H y p o t e n s i o n 62.Apply viscous Lidocaine to oral ulcers as needed. Thirty minutes after shetakes the drug. A s t h m a c . These signs indicatewhich of the following conditions?a . thenurse in-charge should:a.54.o. R esp i r at or y al k al o si s 58. Stacy will re-grow new hair in 3-6 months. The term ―blue bloater‖ refers to a male client which of the followingconditions?a. butmay be different in texture‖. 1 5 m m H g b .c.Flush the IV line with saline solutionc.Inadequate n u t r i t i o n d.E l ev at ed w hi t e bl oo d c e l l co unt d. Pao2 46 mm Hg. Which laboratory test indicates liver cirrhosis?a. V a r i x formationc. pH 7. Gonzales confirms the diagnosis of cirrhosis. 4 0 H g d . Mr.―Maybe your reacting to the drug.Use lemon glycerine swabs every 2 hours. C hr o n i c o bstr u cti v e b r o n chi ti s d . R e s p i r a t o r y acidosis d . C hr o n i c o bstr u cti v e b r o n chi ti s d . No ti f y t he p h ysi c i an b. M e t a b o l i c . During the administration of chemotherapy agents. The term ―pink puffer‖ refers to the female client with which of the followingconditions?a. In cr ease d u r i n e o ut put b.Adult respiratory distress syndrome (ARDS)b .Pulmonary embolismc.The first nursing action to take is:a. This ABG resultrepresents which of the following conditions?a .The biopsy of Mr. I will withhold the next dose‖.temporary. Mr.Im pai r e d cl ot t i ng m e ch ani sm b . the physician orders 50 ml of Lactose p.M eta bo l i c al k al o si s c . Gonzales was admitted to the hospital with ascites and jaundice.D ec r eas e d t en d on r efl ex d .Trauma of invasive procedure61.Provide frequent mouthwash with normal saline. A s t h m a c . E m p h y s e m a 56.―I’ll see if your physician is in the hospital‖. Nurse Oliver observedthat the IV site is red and swollen. 8 0 a c i d o s i s b . Gonzalesis at increased risk for excessive bleeding primarily because of:a . Gozales develops diarrhea.

decreased blood pressure.d.69. N i t r o g l y c e r i n d. After undergoing a cardiac catheterization.Leukocysis.Cardiogenic shockc. decreasedRBC count.It dilates peripheral blood vessels. Whenoffered acetaminophen. E c h o c a r d i o g r a m c . Which of the followingresponses best describes the result?a. Car di a c c at h eter i z ati on b .It inhibits the angiotensin-coverting enzymesd.―Aspirin is avoided because of the danger of Reye’s syndrome inchildren or young adults. Which of the followingresponses by the nurse is appropriate?a. increased blood pressure.c. elevated antinuclear antibody (ANA) titer d. Which of the following steps should the nurse take first?a . Arnold. decreased WBC count. elevated sedimentation ratec.63.Severe lower back pain. Percutaneous transluminal coronary angioplasty (PTCA)66.Kidneys’ retention of sodium and water c.Apply gloves and assess the groin site65.Thrombocytosis.Kidneys’ retention of sodium and excretion of water 68.c. A client with hypertension ask the nurse which factors can cause bloodpressure to drop to normal levels?a. Tracy has a large puddle of bloodunder his buttocks.Appropriate. b.Obtain vital s i g n s c . acetaminophen is strong enough. decreasedRBC count.Elavated serum complement levelb. When evaluating an arterial blood gas from a male client with a subduralhematoma.‖b. decreased RBC count.It decreases sympathetic cardioacceleration. elevated blood urea nitrogen (BUN) and creatinine levels70. The nurse is aware that the following terms used to describe reduced cardiacoutput and perfusion impairment due to ineffective pumping of the heart is:a . A n a p h y l a c t i c shockb. Before discharge.It inhibits reabsorption of sodium and water in the loop of Henle. his mother tells the nurse the headache is severe andshe would like her son to have something stronger.Severe lower back pain. which increases theintracarnial pressure (ICP). decreased blood pressure. . Nurse Nikki knows that laboratory results supports the diagnosis of systemiclupus erythematosus (SLE) is:a. increased WBC count.M y o car di al i nf ar c ti o n ( MI ) 67. he complains of a headache.b. bowel movements are needed to reduce sodium level‖. increased white blood (WBC) count.b.‖71.Kidneys’ excretion of sodium and water d. the nurse notes the Paco2 is 30 mm Hg. decreased re blood cell(RBC) count.―Frequently. Nurse Rose is aware that the statement that best explains whyfurosemide(Lasix)is administered to treat hypertension is:a. increased WBC count.‖c.―I’ll lower the dosage as ordered so the drug causes only 2 to 4 stoolsa day‖.Kidneys’ excretion to sodium only.b.d.Lower back pain.―Narcotics are avoided after a head injury because they may hide aworsening condition.Stronger medications may lead to vomiting.―Your son had a mild concussion. C a l l f o r h e l p . Which of the following treatment is a suitable surgical intervention for a clientwith unstable angina?a.64. decreasedRBC count.Pancytopenia.Distributive s h o c k d . Which of the following groups of symptoms indicates a ruptured abdominalaortic aneurysm?a.Intermitted lower back pain.‖d. decreased blood pressure. a 19- year-old client with a mild concussion is discharged from theemergency department.c.A sk th e cl i en t to ―l i ft up ‖ d.

Above-normal urine and serum osmolality levelsb.Emergent. weakness. E x o p h t h a l m osb.A 50-year-old client with diverticulitis73. I'll eat a snack high incarbohydrates. Norma asks for information about osteoarthritis. and headache. leading the nurse to suspect diabetes insipidus.Above-normal urine osmolality level.D e cr e ase s i nf e cti on c . drink.Tibial m y x e d e m a 76. R e p l a c e s e s t r o g e n b . increasedurination. Cyrill with severe head trauma sustained in a car accident is admitted to theintensive care unit."b. irritability. A 66-year-old client has been complaining of sleeping more. JP has been diagnosed with gout and wants to know why colchicine is usedin the treatment of gout."I can avoid getting sick by not becoming dehydrated and by payingattention to my need to urinate.Belownormal urine osmolality level."c.Frequent u r i n a t i o n 77. Thirty-six hours later.Osteoarthritis is the most common form of arthritisd. the client is poorly oxygenatedc . Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome(HHNS) is stabilized and prepared for discharge.Myxedema c o m a d."I will have to monitor my blood glucose level closely and notify thephysician if it's constantly elevated. Which of the followingstatements about osteoarthritis is correct?a. Ruby is receiving thyroid replacement therapy develops the flu and forgets totake her thyroid replacement medicine.A 17-year-old clients 24hours postappendectomyb. weakness.D e cr e as es i nfl amma ti o n d. the client's urine output suddenly risesabove 200 ml/hour.A 33-year-old client with a recent diagnosis of Guillain-Barre syndromec.Thyroid stormc."79. I should drink aglass of soda that contains sugar. below-normal serum osmolalityleveld."d. the client has alveolar hypoventilation72. depression."If I begin to feel especially hungry and thirsty. The nurse understands that skipping thismedication will put the client at risk for developing which of the following lifethreatening complications?a . Nurse Sugar is assessing a client with Cushing's syndrome. When prioritizing care. Whichlaboratory findings support the nurse's suspicion of diabetes insipidus? a. Based on these ."If I experience trembling. above-normal serum osmolalitylevel78.Osteoarthritis afflicts people over 6075. Whichobservation should the nurse report to the physician immediately?a .Decreases bone demineralization74. N o r m a l d. which of the following statements indicatesthat the client understands her condition and how to control it?a. which of the following clients should the nurse Oliviaassess first? a. When preparing the client for discharge and home management. D r y m u c o u s membranesd.Osteoarthritis is rarely debilitatingb.Osteoarthritis is a rare form of arthritisc.A 50-year-old client 3 days postmyocardial infarctiond.lowering carbon dioxide (CO2) reduces intracranialpressure (ICP)b.A n i r r eg u l ar a pi cal pu l se c . Which of the following actions of colchicines explainswhy it’s effective for gout?a .P i tti n g ed e ma o f t he l e gs b.Si gnificant. or eat more than usual.Below-normal urine and serum osmolality levelsc. anorexia. and bone pain thatinterferes with her going outdoors.

Diabetes mellitusb ."b."81. and its peak to be at 4 p.assessment findings.m. At 2 p.84.Low corticotropin and low cortisol levels82. and its peak to be at 3 p. the nurse should providewhich instruction?a.m. When teachingthe client how to select and rotate insulin injection sites. not amongdifferent regions."86. Nurse Lourdes is teaching a client recovering from addisonian crisis aboutthe need to take fludrocortisone acetate and hydrocortisone at home."c. Nurse Sarah expects to note an elevated serum glucose level in a client withhyperosmolar hyperglycemic nonketotic syndrome (HHNS)."Rotate injection sites within the same anatomic region. Thephysician has prescribed 10 U of U-100 regular insulin and 35 U of U100isophane insulin suspension (NPH) to be taken before breakfast.No increase in the thyroidstimulating hormone (TSH) level after 30minutes during the TSH stimulation testb.b.A de cr e as e d T SH l e ve l c. Preoperatively.High corticotropin and low cortisol levels b.Elevated . and its peak to be at 3 p.Testing for ketones in the urineb. Whichstatement by the client indicates an understanding of the instructions?a.m.Hy p er par at h yr oi di s m80."Inject insulin into healthy tissue with large blood vessels and nerves. D i a b e t e s insipidusc.onset to be at 2 p."b.onset to be at 2:15 p. and its peak to be at 6 p.onset to be at 4 p.m."d.Below-normal levels of serum triiodothyronine (T3) and serum thyroxine(T4) as detected by radioimmunoassay85. NurseMariner should expect the dose's:a. right after I wakeup.An increase in the TSH level after 30 minutes during the TSH stimulationtestd. Insulin is administered using a scale of regular insulin according to glucose results."I'll take all of my hydrocortisone in the morning.Testing urine specific gravityc.m.High corticotropin and high cortisol levelsd.m."I'll take my hydrocortisone in the late afternoon.m. The physician orders laboratory tests to confirm hyperthyroidism in a femaleclient with classic signs and symptoms of this disorder.Checking temperature every 4 hoursd. "I'll take two-thirds of the dose when I wake up and one-third in thelate afternoon.Performing capillary glucose testing every 4 hours83.Low corticotropin and high cortisol levelsc.m. the client has a capillaryglucose level of 250 mg/dl for which he receives 8 U of regular insulin. A male client is scheduled for a transsphenoidal hypophysectomy to removea pituitary tumor. the nurse should assess for potentialcomplications by doing which of the following?a."I'll take the entire dose at bedtime.onset to be at 2:30 p. Rico with diabetes mellitus must learn how to self-administer insulin." c... thenurse would suspect which of the following disorders? a.d.c. Which test result wouldconfirm the diagnosis?a. Capillary glucose monitoring is being performed every 4 hours for a clientdiagnosed with diabetic ketoacidosis."Administer insulin into areas of scar tissue or hypotrophy whenever possible.Which of the following laboratory test results would suggest to the nurse Lenthat a client has a corticotropin-secreting pituitary adenoma?a."Administer insulin into sites above muscles that you plan to exerciseheavily later that day."d. Which other laboratory finding should the nurse anticipate?a. before dinner.Hypoparathyr o i d i s m d .m.

On auscultation of his lung field. no breath sounds arepresent in the upper lobe.Adult respiratory distress syndrome (ARDS)b . A 67-yearold client develops acute shortness of breath and progressivehypoxia requiring right femur. He most likely hasdeveloped which of the following conditions?a.Fracture of the carpal scaphoid89.T uberculosis (TB)94.Restricting intake of oral fluidsb.Pn eumoniac .Fr a c t u r e of t he ol ecr an on c . Johnny a firefighter was involved in extinguishing a house fire and is beingtreated to smoke inhalation.The surgeon fills the space with a gelc. Bubbling soon appears in the water seal chamber. S e r u m a l k a l o s i s d. Hemoptysis may be present in the client with a pulmonary embolism becauseof which of the following reasons?a.S po nta n eo us p n eu mot h or ax 93. L o s s o f l u n g t i s s u e 96. The acid-base disorder that may be present is?a . Cleo is diagnosed with osteoporosis. from the apex to the base.Fat e m b o l i s m 92. A client with shortness of breath has decreased to absent breath sounds onthe right side. A i r . Cal ci um an d p h os ph or o us c . Aldo with a massive pulmonary embolism will have an arterial blood gasanalysis performed to determine the extent of hypoxia. P n e u m o n i a d . He’s now in the emergency department complaining of difficulty of breathing and chest pain.Involvement of major blood vessels in the occluded areac. C a l c i u m a n d s o d i u m b . B r onchi t i s d. This client may have which of the following conditions?a .The space remains filled with air onlyb. what fills the area of the thoraciccavity?a. Which of thefollowing is the most likely cause of the bubbling?a . A 62-year-old male client was in a motor vehicle accident as an unrestraineddriver. Armand an 22-year-old client is admitted witha pneumothorax.Alveolar damage in the infracted areab.Fr a ct ur e of t he d i st al r a di u sb . A s t h m a attackb. B r onchitis d . Which of the following conditions wouldbest explain this?a . M e t a b o l i c acidosisb. Which electrolytes are involved in thedevelopment of this disorder?a . The surgeon inserts a chest tube and attaches it to a chestdrainage system. For a client with Graves' disease. A t e l e c t a s i s c . If a client requires a pneumonectomy.Respiratory a c i d o s i s d . which nursing intervention promotescomfort?a.Below-normal serum potassium level87.Limiting intake of highcarbohydrate foodsd. B r o n c h i t i s b.The tissue from the other lung grows over to the other side95.Fr a ct ur e of t he hu mer us d. What is a Colles' fracture?a . A c u t e a s t h m a b. requiring intubation and mechanical ventilation.Chronic bronchitisc .Maintaining room temperature in the lownormal range88.Atelectasisc.P o ta ssi um a n d so di um 90. Patrick is treated in the emergency department for a Colles' fracturesustained during a fall.Placing extra blankets on the client's bedc.R es pi r at or y al k al o si s 97. P n e u m o t h o r a x d. He develops severe hypoxia 48 hours after theincident.serum acetone levelb.P h osp h or o u s a n d p otas si u md . After a motor vehicle accident. S er um k eto n e bo di es c . The hypoxia was probably caused by which of thefollowing conditions?a .Metabolic alkalosisc.Serous fluids fills the space and consolidates the regiond. Lo ss o f l u n g p ar en c hy ma d . P n e u m o n i a 91.

b.T he c l i e nt i s har m f ul to oth er s. 1 8 b .―I will wear the stockings until the physician tells me to remove them. c . He begins cursing and throwing furniture. not being able to sleep at night.Place the client in full leather restraints.‖ The Nurse isusing which therapeutic technique?a . but now complainsthat it ―doesn’t help‖ and refuses to take it.4.Tony refuses his evening dose of Haloperidol (Haldol). a 6-year-old child with a congenital heart disorder is admitted withcongestive heart failure.T he cl i en t i s d i sr up ti v e. The nurse would not let this client join the group session because:a .P er c e pt u al d i s or d er s . Nurse John responds to the client.Tina who is manic.Inadequate suctiond. Re c en t al coh ol i nt ak e. 4 0 99. Digoxin (lanoxin) 0.M. indicates to the nurse that theteaching was successful? a.Care of Clients with Physiologic and Psychosocial Alterations 1. Which of thefollowing statements. I m p e n d i n g c o m a .l e a k b. The nurse shouldregulate the client’s IV to deliver how many drops per minute?a . The mother says that she isafraid of what the father might say to the boy. andfeeling upset with his wife.Restatingc.The client needs to be on medication first.Refer the mother to the hospital social worker. then becomesextremely agitated in the dayroom while other clients are watchingtelevision. an adolescent boy was admitted for substance abuse andhallucinations.―Every four hours I should remove the stockings for a half hour. c . Theclient receives 3. Marquez reports of losing his job. 5 m l b .Dervid.‖b.000 ml of Ringer’s lactate solution IV to run over 24 hours. 6.Agree to talk with the mother and the father together. 4 .‖c. 2 m l c .Explorin g d . b . if made . F o c u s i n g 2.05 mg of Lanoxin in 1 ml of solution.12 mg is ordered for the child. 2 m l 100.dose of medication for agitation. 3 5 d . O b s e r v a t i o n s b . 2 1 c .Kinked chest t u b e 98. d.‖ TEST V . Nurse Michelle calculates the IV flow rate for a postoperative client. The most appropriatenursing intervention would be to:a. What should the nurse say Mickey. Nurse Oliver firstaction is to:a. TheIV infusion set has a drop factor of 10 drops per milliliter. What amountshould the nurse administer to the child?a .b. 3 .d.d.What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? a .Adequate suctionc.3.D epr es si o n w i t h m ut i s m.c. d .Inform the mother that she and the father can work through thisproblem themselves.T he cl i en t i s h ar m ful t o s el f . 1 .Suggest that the father and son work things out.Aira has taken amitriptyline HCL (Elavil) for 3 days.c.Call the attending physician and report the behavior.Mr. but not yet on medication. by the client.‖d. 4 m l d .Remove all other clients from the dayroom. b .―I should put on the stockings before getting out of bed in the morning. The client’s mother asks Nurse Armando to talk with hishusband when he arrives at the hospital.―I should wear the stockings even when I am sleep. Thebottle of Lanoxin contains . Nurse Alexandra teaches a client about elastic stockings. comes to the drug treatmentcenter. 2 .Check the client’s medical record for an order for an as-needed I. ―You maywant to talk about your employment situation in group today.5.

Increase calories.By calling attention to or attempting to prevent the behavior.d. this behavior may belargely attributed to a developmental defect related to the:a . It is important for the nurse to understand the psychodynamically. NurseMichelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?a .The adolescent denies stealing. We'll workon .c. Ruby returns to the clinic. Which nursingintervention is most appropriate for Ruby?a.d . not physical.By designating times during which the client can focus on thebehavior. an adolescent has a history of truancy from school.b.When physical examination rules out a physical cause for her paralysis. carbohydrates. carrots."Your problem is real but there is no physical basis for it.Decreased oral and respiratory secretions. she complainsthat her legs are paralyzed and is rushed to the emergency department."c.Flat a f f e c t b.Suggest that it takes awhile before seeing the results. decrease fat. and appleslices.Nurse Lynnette notices that a female client with obsessive- compulsivedisorder washes her hands for long periods each day. and decrease protein. d. rationalizing instead that as long as noone was using the items.Sk el etal m us cl e p ar al ysi s.Recommending a high-protein.b.c. Nurse Gina is aware that the dietary implications for a client in manicphase of bipolar disorder is:a.or do?a .complaining of fear. d . A n a l g e s i a .S h or t .Giving sleep medication. b.By discouraging the client from verbalizing anxieties. to restore a normal sleep-wake cycle.10. Meryl asks the nurse. S u p e r e g o d.Acting overly solicitous toward the child.You must deal with this conflict if you want to walk again."You've developed this paralysis so you can stay with your parents.Give the client pieces of cut-up steak. Ruby who wasraped while walking her dog is diagnosed with posttraumatic stressdisorder (PTSD). and protein. I d b .After seeking help at an outpatient mental health clinic. W i t h h o l d t h e d r u g .d. 11. and an apple. Shortly before the semester starts. "Why has this happenedto me?" What is the nurse's best response?a."It must be awful not to be able to move your legs."b.b. as prescribed. Three months later. buttered French bread.7.Record the client’s response.Encourage the client to tell the doctor. it was all right to borrow them. and helpless feelings.Meryl.What parental behavior toward a child during an admission procedureshould cause Nurse Ron to suspect child abuse? a. is highly dependent on her parents and fears leaving hometo go away to college. running awayfrom home and ―barrowing‖ other people’s things without their permission.d. age 19. A l l ow i ng t h e cl i e nt t i me t o h eal .Serve the client a bowl of soup. How should thenurse respond to this compulsive behavior?a.Increase calories.13.the physician admits her to the psychiatric unit where she is diagnosedwith conversion disorder. You may feelbetter if you realize the problem is psychological.12. 9.c.In preparing a female client for electroconvulsive therapy (ECT).Dervid. loss of control.By urging the client to reduce the frequency of the behavior asrapidly as possible.Expressing g u i l t c.c .Oedipal c o m p l e x 8. low-fat diet.c . I g n o r i n g t h e c h i l d .Exploring the meaning of the traumatic event with the client.a ct i n g a ne st he si a b. E g o c .

A 65 years old client is in the first stage of Alzheimer's disease.Richard with agoraphobia has been symptom-free for 4 months. what is its onset of action?a . 3 to 5 daysc."d.b. 10 mg by mouth twice per day. and grandiose ideationc. euphoria.A warning about the drugs delayed therapeutic effect. Opiate withdrawal causes severe physical .Anticholinergicsc .chlordiazepoxide (Librium) and diazepam (Valium)c.10 to 14 days 19.6 to 8 days d.Insomnia and an inability to concentrate.b.Providing emotional support and individual counseling. cruelty to animals.A warning about the incidence of neuroleptic malignant syndrome(NMS). andstealing.Suggesting new activities for the client and family to do together.d. A n t i p s y c h o t i c s d.Which medications have been found to help reduce or eliminate panicattacks?a .Suspiciousness.c. the physician prescribes tranylcyprominesulfate (Parnate).Demonstrated ability to maintain close.D epr es si o n an d w ei ght l oss . which is from14 to 30 days.Emotional lability.Agitation. Which signs would suggest an overdose of anantianxiety agent?a.divalproex (Depakote) and lithium (Lithobid)15. The nurse is aware that the teachinginstructions for newly prescribed buspirone should include which of thefollowing?a. 1 t o 2 d a y s b . The physicianprescribed buspirone (BuSpar).d. hyperactivity.benztropine (Cogentin) and diphenhydramine (Benadryl).The nurse is caring for a client diagnosed with antisocial personalitydisorder. Which of the following traits would the nurse be most likely touncover during assessment?a .A low tolerance for frustration22.Nurse Krina knows that the following drugs have been known to beeffective in treating obsessivecompulsive disorder (OCD):a.20.A reminder of the need to schedule blood work in 1 week to checkblood levels of the drug. NursePatricia should plan to focus this client's care on:a. Se ver e a nxi et y an d f ear .Nurse Amy is providing care for a male client undergoing opiatewithdrawal.A client seeks care because she feels depressed and has gained weight. dilated pupils.fluvoxamine (Luvox) and clomipramine (Anafranil)d.Monitoring the client to prevent minor illnesses from turning intomajor problems."It isn't uncommon for someone with your personality to develop aconversion disorder during times of stress.17. Classicsigns and symptoms of phobias include:a. and increased blood pressure21. When this drug is usedto treat atypical depression.what is going on in your life to find out why it's happened. sweating.Frequent expression of guilt regarding antisocial behavior c.Alfred was newly diagnosed with anxiety disorder. A n t i d e p r e s s a n tsb.Mood s t a b i l i z e r s 18. The client has a history of fighting. d.Offering nourishing finger foods to help maintain the client'snutritional status. c . and confusionb.To treat her atypical depression.H i s t or y of g ai nf ul e m pl o ym en t b. and impaired memoryd.b." 14.c.Withdrawal and failure to distinguish reality from fantasy.The nurse is assessing a client who has just been admitted to theemergency department.b.A warning that immediate sedation can occur with a resultant dropin pulse. stable relationshipsd.Combativeness.16.

‖32.Richard is admitted with a diagnosis of schizotypal personality disorder. R e p r e s s i o n d .Rudolf is admitted for an overdose of amphetamines.‖ The client asks if the nurse hears the voices.Identify anxiety-causing situationsd . Nurse Marco is developing a plan of care for a client withanorexianervosa.Avoid shopping for large amounts of food.Set up a strict eating plan for the client.c. ―The voices aretelling me I’m no good.Confusion for .T en si o n a nd i r r i t abi l i t y b .c.d. D e n i a l 28.d. Co nt r ol e ati n g i mp ul s es . the nurse should expect to see:a .27.Provide privacy during meals.Offering a high-calorie meals and strongly encouraging the client tofinish all food. the voices are a symptom of your illness.Nurse Jen is caring for a male client with manic depression.―It is the voice of your conscience. B a r b i t u r a t e s b .Loose associationsd .―Oh. S l o w pul sec. but I believe you can hear them‖.‖b. Themost appropriate response by the nurse would be:a. M e t h a d o n e d .Restricts visits with the family and friends until the client begins toeat.―No. which will reduce her anxiety. The nurse isaware that this diagnosis reflects a belief that one is:a.b. L o s s o f a p p e t i t e b .H i g hl y i mp or ta nt or f am ous .―The voices are coming from within you and only you can hear them.b. B e i n g p e r s e c u t e d c. c. When assessing theclient.Insisting that the client remain active through the day so that he’llsleep at night. b .P os t ur al h y p ot e nsi on c. To minimize these effects.Which signs would this client exhibit during social situations?a.A g gr e ssi v e b e hav i or b . The plan of care for a client in a manic state would include:a. demanding. Which action should the nurse include in the plan?a. don’t pay anyattention to them. L o g ical thinkingc . H a l l u c i n ations c. D e l u s i o n s b .H ypot en si on d. I do not hear your voices. 30. N e o l o g i s ms 24.The most appropriate initial goal for a client diagnosed with bulimia is to:a.E at o nl y t hr e e m eal s p er d ay .Independence needs 29. which only you can control.Emotional affectd.Listening attentively with a neutral attitude and avoiding power struggles. A m p hetaminesc .b.Ramon is admitted for detoxification after a cocaine overdose. opiate users are commonlydetoxified with:a . C o n s t i p a t i o n 31.Responsible for the evil in the world. These perceptions are known as:a .25. manipulativebehavior without setting limits. The clienttells the nurse that he frequently uses cocaine but that he can control hisuse if he chooses.discomfort and canbe lifethreatening.26.Tim is admitted with a diagnosis of delusions of grandeur. B e n z o d i a z e p i n e s 23. Nurse Mickey is caring for a client diagnosed withbulimia.‖d.c.Nicolas is experiencing hallucinations tells the nurse. P a r a n o i d thoughts c.Nurs e Cristina is caring for a client who experiences false sensoryperceptions with no basis in reality.The nurse is aware that the side effect of electroconvulsive therapy that aclient may experience:a . W i t h d r a w a l b .Connected to events unrelated to oneself d. Which coping mechanism is he using?a .Allowing the client to exhibit hyperactive.Encourage the client to exercise.

l ev el a nxi et y c .Inability to urinate or difficulty when urinating42.Encouraging the client to have blood levels checked as ordered. S e v e r e . R i g i d i t y b .Taking medications containing aspirin36.o t. The student’s ability to ignoredistractions and to focus on studying demonstrates:a .d.Complete loss of memory for a time33.Advising the client to watch the diet carefullyb.Staying in the s u n c .Diver s e i n t e r e s t d . A n g e r st ageb. Nurse Katrina would be aware that the teaching about the sideeffects of this drug were understood when the client state. R e s p e c tc. thenurse should include cautioning the client against:a .Adaptation and a return to a prior level of functioning.Loss of abstract thinking related to emotional statec.P a ni c.Sensitivity to bright light or sunb.Sexual dysfunction or breast enlargementd.Fine hand tremors or slurred speechc.As they lose interest in the environment 39.Miranda a psychiatric client is to be discharged with orders for haloperidol(haldol) therapy.Presen c e 43.When their depression is most severec. When developing a teaching plan for discharge.A higher level of anxiety continuing for more than 3 months.When establishing an initial nurse-client relationship.Before nay type of treatment is startedd.I n ge sti ng wi n es a n d c h e es es d.Bargaining stage d .Decompensation to a lower level of functioning.35.l e v e l a n x i e t y b .O ver m et i c ul o us ne ss 38. In theteaching plan for discharge the nurse should include:a.l e v e l a n x i e t y d.Reminding the client that a CBC must be done once a month.c.As their depression begins to improveb.Client’s perception of the presenting .a time after treatmentd.i.Josefina is to be discharged on a regimen of lithium carbonate.Learning more constructive coping skillsb. M i l d .When assessing a premorbid personality characteristics of a client with amajor depression.Nurse Krina recognizes that the suicidal risk for depressed client isgreatest:a.Nurse Kate would expect that a client with vascular dementis wouldexperience:a.Jen a nursing student is anxious about the upcoming board examinationbut is able to study intently and does not become distracted by aroommate’s talking and loud music. Basing care on the theory of Kubler-Ross.Nurse Trish plans to use nonverbal interventions when assessmentreveals that the client is in the:a .Suggesting that the client take the pills with milkc.d. P r i v a c y b .Denial s t a g e c.A dying male client gradually moves toward resolution of feelingsregarding impending death.d for a femaleclient. D r i v i n g a t nightb.Empathyd. it would be unusual for the nurse to find that this clientdemonstrated:a . ―I will call mydoctor immediately if I notice any:a.40.Loss of remote memory related to anoxiab.41.The psychiatrist orders lithium carbonate 600 mg p. S t u b b o r n n e s s c.The outcome that is unrelated to a crisis state is:a. Nurse Hazel shouldexplore with the client the:a.l ev el a nxi et y 37. Mo d er at e .Nurse Mylene recognizes that the most important factor necessary for theestablishment of trust in a critical care area is:a . A c c e p t a n c e s t a g e 34.Inability to concentrate related to decreased stimulid.Disturbance in recalling recent events related to cerebral hypoxia.

aged cheese. insomnia. poor concentration.b.Consulting with the physician about substituting a different type of antidepressant. Which response by the nurse would be mostappropriate?a. poor appetite. 51.Advising the client to sit up for 1 minute before getting out of bed. ―I will avoid: a. c. and diaphoresis. and yellow vegetables. fever."Your cursing is interrupting the activity."Your behavior won't be tolerated. Dervid with paranoidschizophreniarepeatedly uses profanity during anactivity therapy session."48. Which nursing intervention would be most appropriate if a male clientdevelop orthostatic hypotension while taking amitriptyline (Elavil)?a.Ricky with chronic schizophrenia takes neuroleptic medication is admittedto the psychiatric unit.d. and difficulty making decisions. Nursing assessment reveals rigidity.Nurse John is a aware that most crisis situations should resolve in about:a . Cruz visits the physician's office to seek treatment for depression. These findings suggest which life-threatening reaction:a.4 to 6 mont hs d."b.feelings of hopelessness.Mr.50. red meats.Blood pressure must be monitored for hypertension. i mi pr ami n e ( T ofr a ni l ) 49.problem. tuna.hypertension.d .Occurrence of fantasies the client may experience.6 to 12 m o n t h s 46.Monthly blood tests will be necessary. After teaching the clientabout the medication.c. Neuroleptic malignant syndrome.Chocolate milk.Informing the client that this adverse reaction should disappear within 1 week.Citrus fruit. Take time out in your roomfor 10 minutes.Females talk more about suicide before attempting itd. A k a t h i s i a .Report a sore throat or fever to the physician immediately.Instructing the client to double the dosage until the problemresolves.Stop the medication when symptoms subside. c hl or di az ep oxi d e ( Li br i um) c .44. chicken. b . Nurse Judy knows that statistics show that in adolescent suicidebehavior:a.‖b. and carbonated soda.b. low self-esteem. The .Details of any ritualistic acts carried out by the client d.Nurse Maureen knows that the nonantipsychotic medication used to treatsome clients with schizoaffective disorder is:a . 1 t o 2 weeksb.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client whohas not responded to the tricyclic antidepressants.d. c."d. and milk.Females use more dramatic methods than malesb.Males account for more attempts than do femalesc. Nurse Marian evaluates that learning has occurredwhen the client states.Whole grains."c. controls are instituted. and yogurt’‖c.‖d. You can't control yourself even for a fewminutes."You're just doing this to get back at me for making you come totherapy.Client’s feelings when external. Go to your room immediately.l i t hi um c ar bo nat e ( Li t ha n e) d.Males are more likely to use lethal methods than are females 47.Green leafy vegetables.Which information is most important for the nurse Trinity to include in ateaching plan for a male schizophrenic client taking clozapine (Clozaril)?a. fatigue.b. D y s t o n i a .4 to 6 weeksc."I'm disappointed in you.52.c. Tar di v e d y sk i n es i a. ph en el z i ne ( Nar di l ) b.‖ 45.

C y cl ot h ymi c d i s or d er .Inability to perform self-care activities.Isabel with a diagnosis of depression is started on imipramine (Tofranil). the nurse Tyfany suspects:a . Can ni b i s w i t h dr aw a l c .This medication may be habit forming and will be discontinued assoon as the client feels better. Which statement about delirium is true?a.c. andlacrimation.57.30 g mi xe d i n 2 5 0 ml of wa ter d. The nurseassesses the client and notes piloerection.It's characterized by an acute onset and lasts hours to a number of days.Cely with manic episodes is taking lithium.b. After taking an overdose of phenobarbital (Barbita). To promote the client's physical health.Occasional irritable outbursts. d.and chicken livers while taking the medication.clientstates that these symptoms began at least 2 years ago.Chlorided.b.Severely restrict the client's physical activities.It's characterized by a slowly evolving onset and lasts about 1week. The nurse should tell the client that:a. S o d i u m c. Which electrolyte level shouldthe nurse check before administering this medication?a . is nowbeing prescribed in the United States?a . 53. The nurse suspects that the client is going through which of the following withdrawals?a . To assess for progression to the middle stage of Alzheimer's disease.59.Weigh the client daily. Trinidad prescribes activated charcoal(Charcocaps) to be administered by mouth immediately. Im pai r ed c o mmu ni ca ti o n.Edward.Nurse Josefina is caring for a client who has been diagnosed withdelirium.What herbal medication for depression.5 g mi xe d i n 250 ml o f wat er b . 6 0 g mi xe d i n 500 ml o f wat er 54. Based on thisreport. a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of theAlzheimer's type.Monitor vital signs.Kathleen is admitted to the psychiatric clinic for treatment of anorexianervosa. widely used in Europe.It's characterized by a slowly evolving onset and lasts about 1month. C o c a i n e . c. E p h e d r a 55.60.P o t a s s i u m 56.This medication has no serious adverse effects.d. after the evening meal. Dr.1 5 g mi xe d i n 5 00 ml o f wa ter c . the nurse verifies the dosage ordered. serum electrolyte levels.A t y pi cal a ff e cti ve di s or der . c . and acid-base balance. Shecomplains of nausea and vomiting 24 hours after admission.b. John's w o r t d . L a c k o f s p o n t a n e i t y .75 mg by mouth at bedtime.b . Beforeadministering the dose.D yst hy mi c d i s or d er . A l c o h o l w i t h d r a w a l b .d.c. Early signs of this dementia include subtle personalitychanges and withdrawal from social interactions.Celia with a history of polysubstance abuse is admitted to the facility.58.This medication may initially cause tiredness.E chi na c ea c. the nurse should plan to:a. d . c . M a j o r d e p r e s s i o n . C a l c i u m b .Instruct the client to keep an accurate record of food and fluidintake. Mario is admitted to the emergency department. the nurse shouldobserve the client for:a. which should becomeless bothersome over time. What is theusual minimum dose of activated charcoal?a .d. pupillary dilation.The client should avoid eating such foods as aged cheeses. G i n k g o bilobab.St.b. yogurt.It's characterized by an acute onset and lasts about 1 month.

H e r o i n b . She is diagnosed to have Mental retardation of thisclassification:a . The side effects of the following may be noted by the nurse:a.tongue. P r o j e c t i o n c.The therapeutic approach in the care of Armand an autistic child includethe following EXCEPT:a. Agoraphobiab .Mr.Dennis has a lithium level of 2.Marij u a n a 69.The client feels angry towards the nurse who resembles his . X e n o p h o b i a 71. Nurse Annewould most likely observe:a.d. 63.Moderate d .Jeremy is brought to the emergency room by friends who state that hetook something an hour ago.Nurse Anne is caring for a client who has been treated long term withantipsychotic medication.c. Garcia.Increased attention span and concentrationb . with irritated nasal septum.Q. Cl o u di n g o f c o ns ci ou sn es sd . S e v e r e 67.Nurse Pauline is aware that Dementia unlike delirium is characterized by:a .Reactionf o r m a t i o n d.Abnormal movements and involuntary movements of the mouth. a 9 year old child has very limited vocabulary and interaction skills.Kitty.A 35 year old female has intense fear of riding an elevator. R e g r e s s i o n b . The nurse immediately wouldassess the client for which of the following signs or symptoms?a .She has an I.withdrawald. and ataxia. W e a k n e s s b . agitated.B r a d y car di a a n d d i ar r he a 66.Fecal i n c o n t i n e n c e 64.Nurse Irish is aware that Ritalin is the drug of choice for a child withADHD.Focusing on the feelings of the client. Nurse Beatriz knows that the client'sbehavior most likely represents the use of which defense mechanism?a .Confronting the client about discrepancies in verbal or non-verbalbehavior d.65.a . of 45. If tardive dyskinesia is present. flushing.Rearrange the environment to activate the child68.Severe hypertension.Opioid w i t h d r a w a l 61.Claustrophobi a d .The client verbalizes the reasons for the violent behavior.Blurred v i s i o n d.The administered medication has taken effect. This is evidencedby:a. migraine headache.Revealing personal information to the clientb. C o c a i n e c .Engage in diversionary activities when acting -outb. S o c i a l phobiac. Nurse Anne checks theclient for tardive dyskinesia.d. P r ovi d e s af et y m eas ur es d. Nurse determines that it will be safe toremove the restraints when:a. D i a r r h e a c.No acts of aggression have been observed within 1 hour after therelease of two of the extremity restraints. She claims ―As if I will die inside.‖c.S e ns or y p er c ep t ua l c ha n ge 70.Nurse Jannah is monitoring a male client who has been placed inrestraintsbecause of violent behavior. During the assessment. He is actively hallucinating.The client apologizes and tells the nurse that it will never happenagain.Sl e epi n ess a n d l et har gy d .Provide an atmosphere of acceptancec . P r o f o u n d b .Insidious o n s e t c . L S D d. M i l d c. I n t el l e ct ual i z a t i on 62. S l u r r e d s p e e c h b. an attorney who throws books and furniture around the officeafter losing a case is referred to the psychiatric nurse in the law firm'semployee assistance program.‖ The client is suffering from:a.b.c. and face. tremors.Severe headache.I n cr ea se i n a p pet i te c .4 mEq/L.b.Nurse Myrna develops a countertransference reaction.Abnormal breathing through the nostrils accompanied by a ―thrill.

Charina. A living. O b e s i t y b. Which of the followingstatements indicates a positive client response?a. A cognitive approach to change behavior c. Situationalb. These symptomsare typically of which of the following disorders?a. T r a n s f e r e n c e c.Tristan is on Lithium has suffered from diarrhea and vomiting.―I went . a newly admitted is extremely hostile toward a staff member shehas just met. These symptoms indicate which of thefollowing disorders?a.Borderline personality disorder c . Which of the following best describes a therapeutic milieu?a. the studentcontinues to express her belief that she has a serious illness.R i s per i d on e ( Ri s p er d al ) 81.Nurse Sarah ensures a therapeutic environment for all the client.It promotes emotional support or attention for the client82. Dervid is diagnosed with panic disorder with agoraphobia is talking with thenurse in-charge about the progress made in treatment. H y p o c h o n d r i a s i s d.Marielle.P ar oxe t i ne (P axi l ) \ c . D e p e r s o n a l i z a t i o n c .An 83year-old male client is in extended care facility is anxious most of thetime and frequently complains of a number of vague symptoms thatinterfere with his ability to eat. Reassure the client that these are common side effects of lithiumtherapyd. Tr i az ol am ( H al ci o n )b . Developmentald . M a j o r depressiond . Hold the next dose and obtain an order for a stat serum lithiumlevel73. H y p er t e n s i o n 77. A permissive and congenial environment74.Triangulationd. Co nv er si on d i s or d er b . Heis manifesting:a . Internal 76. S p l i t t i n g b . Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders. d.72. TextRevision (DSM-IV-TR) is:a .It decreases the preoccupation with the physical illnessc. H y p o c h o n d r i a s isc. Rape is an exampleof which type of crisis:a .mother. F l u o x e t i n e ( P r o z a c ) d .Katrina. S u b l i m a t i o n 79. T r a n s f e r e n ce c.It enables the client to avoid some unpleasant activityd. According to Freudian theory. Whatshould the nurse in-charge do first:a. Although physical causes have been eliminated. Aldo.It brings some stability to the familyb. Adventitiousc. without apparent reason. Which of the following statement refers to a secondary gain?a. S o mat i z at i o n di sor d er 80.Anthony is very hostile toward one of the staff for no apparent reason. Co nv er si on d i s or d er b . learning or working environment. G i v e t he c l i en t C og e nti n c. She is brought to the hospital by her mother. R e s i s t a n c e 75. with a somatoform pain disorder may obtain secondary gain. thenurse should suspect that the client is experiencing which of the followingphenomena?a .I nt el l e ct u al i z at i o n b . 17 years old was sexually attacked while on her way home fromschool. Countertransferenced . a college student who frequently visited the health center during thepast year with multiple vague complaints of GI symptoms before courseexaminations. Recognize this as a drug interactionb . S e v e r e a n x i e t y d . A therapy that rewards adaptive behavior b. Nurse Daisy is aware that the following pharmacologic agents are sedative-hypnotic medication is used to induce sleep for a client experiencing a sleepdisorder is:a. Spl i t t i n g 78.

the client says.Stopping the drug decreases sleeping difficultiesd. Ricardo. I ’ve l ost m y ph ob i a for wa ter ‖ 84.The client becomes anxious whenever the nurse leaves thebedsided. Mark.―Last night I decided to eat more than a bowl of cereal‖ 83. This client’s impairment may be related towhich of the following conditions?a .It’s a mood disorder similar to major depression but of mild tomoderate severity87. Jennifer.Vascular dementia has more abrupt the mall with my friends last Saturday‖b.and diazepam (Valium) for anxiety.Stopping the drug may cause depressionb. Which of the following .91.The client is experiencing dysarthriac.―I’m not losing my temper as much‖c. a newly admitted client was diagnosed with delirium and has historyof hypertension and anxiety.The client is experiencing visual hallucination90.It involves a mood range from moderate depression to hypomaniab. I n f e c t i o n b . The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in aclient with posttraumatic stress disorder can be demonstrated by which of thefollowing client self – reports?a.It involves a single manic depressionc.―I’ve lost my craving for alcohol‖ d .Drug i n t o x i c a t i o n d .C o gni ti v e i m pai r me nt d . Which of the following other health problems would the nursesuspect?a . ―I keep hearing a voice telling me to run away‖c.The client is experiencing a flight of ideasd.―I’m hyperventilating only when I have a panic attack‖c.Personality change is common in vascular dementiad.He pat i c e n c ep hal o pat hy 89. During conversation of Nurse John with a client. The nurse is aware that the following ways in vascular dementia differentfrom Alzheimer’s disease is:a.The client says. M e tabolic acidosis c. Which of the following descriptions of a client’s experience and behavior canbe assessed as an illusion?a.―I’m sleeping better and don’t have nightmares‖b. She had been taking digoxin. Nurse Ron enters a client’s room. A n x i e t y d i s o r d e r b. furosemide (Lasix). Loretta.The client tries to hit the nurse when vital signs must be takenb.―Today I decided that I can stop taking my medication‖d. L a b i l e m o o d s 86.It’s a form of depression that occurs in the fall and winter d.The duration of vascular dementia is usually brief c.Stopping the drug increases cognitive abilitiesc. Which of the following statement about dysthymic disorder is true?a. an adolescent who is depressed and reported by his parents ashaving difficulty in school is brought to the community mental health center to beevaluated.The client looks at the shadow on a wall and tells the nurse shesees frightening faces on the wall.Stopping the drug can cause withdrawal symptoms85. he observes that the clientshift from one topic to the next on a regular basis.The inability to perform motor activities occurs in vascular dementia88. ―They’re crawling on mysheets! Get them off my bed!‖ Which of the following assessment is the mostaccurate?a.The client is experiencing aphasiab.B e havi or al d i ffi c ul ti es c . an outpatient in psychiatric facility is diagnosed with dysthymicdisorder. Which of the following important facts should nurse Bettydiscuss with the client about discontinuing the medication?a. with a diagnosis of generalized anxiety disorder wants to stop takinghis lorazepam (Ativan).

termsdescribes this disorder?a . R e g r e s s i o n d . she says. S c h i z o t y p a l 93.Ideas of referenced.Use a sunscreen outdoors on a year-round basisc.D i sor ga ni z ed s p ee c h c . who is on the psychiatric unit is copying and imitating the movements of her primary nurse.Concrete thinkingc. R a t ionalizationc . Which of the following interventions is important for a Cely experiencing withparanoid personality disorder taking olanzapine (Zyprexa)?a. H i st r i oni c c .Explain effects of serotonin syndromeb. R e p r e s s i o n 100. the client becomes argumentative. Rocky has started taking haloperidol (Haldol). Ivy. Co ns tan t n e e d f or att ent i o n 95. P a r a n o i d d.Egosyntonicityd . with dependent personality disorder is working to increase his selfesteem.‖ This behavior is known bywhich of the following terms?a . Thisbehavior shows personality traits associated with which of the followingpersonality disorder?a . P r o j e c t i o n b .Which of the following interventions should be done first?a. Nurse Alexandra notices other clients on the unit avoiding a client diagnosedwith antisocial personality disorder.Call his physician to get his medication increased to control hispsychosis97. D e l u s i o n b . Which of the followinginstructions is most appropriate for Ricky before taking haloperidol?a.This drug . R i t u a l i s m 98. I d e a o f r e f e r e n c e 99.―I’m most concerned about my level of competence and progress‖c.Teach the client to watch for extrapyramidal adverse reaction c. F l i g h t o f i d e a s b.S how o f t em per t antr ums d . Francis tells the nurse that her coworkers are sabotaging the computer.Explain that the drug is less affective if the client smokesd.Discuss the need to report paradoxical effects such as euphoria94. M o d e l i n g b .―I find I can’t stop myself from taking over things other should bedoing‖96.Talk about his hallucinations and fearsb.Loose a s s o c i a t i o n 92. Which of the following statements by the Tommy shows teaching wassuccessful?a. During recovery. I felt connected only when I saw my nurse.―I’m not going to look just at the negative things about myself‖b. Jun approaches the nurse and tells that he hears a voice telling him that he’sevil and deserves to die.Be aware you’ll feel increased energy taking this drugd. A n t i s o c i a l b . Which of the following defense mechanisms is probably used bymike?a . Which of the following terms describes the client’sperception?a . L a c k o f h o n e s t y b .Refer him for anticholinergic adverse reactionsc. B el i ef i n s u per s ti ti on c .Should report feelings of restlessness or agitation at onceb. Shescratches while she tells the nurse she feels creatures eating away at her skin.When the nurse asks questions. H a l l u c i n a t i o n d . Norma. E c h o p r a x i a c. a 42-year-old client with a diagnosis of chronic undifferentiatedschizophrenia lives in a rooming house that has a weekly nursing clinic. Tommy. which of the following comments is expected about this client byhis peers?a . Mike is admitted to a psychiatric unit with a diagnosis of undifferentiatedschizophrenia.Assess for possible physical problems such as rashd. When discussing appropriate behavior ingroup therapy.―I’m not as envious of the things other people have as I used to be‖d. ―I thought the nurse was mymirror.

I wasn’t even nervous or a little bit anxious and frankly.will indirectly control essential hypertension Posted on Saturday. 2010 No Comments your mind. 2. A happy brain retains and understands more than an anxious one. I was so nervous that I found myself converting my anxiety into physical symptoms. Doubt is a buzz killer. RN (#10 December 2007NLE) I’ve been where you are right now. I suggest chocolate. Avoid erasures. In fact. Rest and relax at least a day before. Remember that. it might as well be so). While studying: 1. scared or doubtful. Make this a ―spirit-lifter‖ everyday and whenever you’d feel sad. 2. Believe in yourself that you can do it: that you can reach the top. Tips from CBRC’s recent topnotchers: Shayne Caseria. Hindi kajolog-san ang magbaon ng food. If the top means that you’ll become a topnotcher. 3. Tell God why you want to pass and ask for His guidance. The first time. especially during these times that the exam date is creeping near everyday. Pray for a good gut feel and divine intervention when faced with eliminating answers or guessing. January 09. Imagine how it would feel. Reward yourself. Be early and bring everything that you need. Never ever let any doubt creep into Before the boards: 1. I’ve actually been there twice. in other words ―kontra‖. Concept map helps . my second try at the boards was quite different. I was quite excited to take the exam already because I know that I can soar Tips from NLE Topnotchers high and reach the top. Set realistic goals and reach them. Blogger's note: Found these tips from Carl Balita Review Center's website and it's worth reading especially for those students who will take up NLE this year. persists‖. yung expensive na. RN (#8 June 2008 NLE) During the boards: 1. Good luck colleagues!!! Carla Barbon. so be it! to simplify ideas and increase retention. Don’t sabotage yourself by doubting or fearing that you will fail (because if you do. keep it light. This would truly do wonders. Prioritize concepts and procedures. So smile. 2. ―whatever you resist. Mahirap nab aka ma-void ang answer sheet mo. Visualize and see it in your mind that you’ve reached your goal. In contrast. about to take the boards.

I recommend videoke. It is an enumeration of things that I did in my preparation for the board exams. Tutal. I would usually allot 2-3 hours of my time each night to read. it can be done. It is a great sense of achievement that I think everyone who is willing to work hard should experience. Hence. So after 4 years in nursing school. dream of topping it. No stress. (note: Only if you have the time and the drive. RN (#8 June 2008 NLE) 1. I started to review for the board exams a full 4 months before the examination date. nagreview ka pa. then dream big. Be confident! Nakagraduate ka nga. spend the last day before the exam on relaxation. I’ve always thought that nursing is a combination of all health-related courses rolled into one. God Bless! Zyena Joyce Untalasco.3. Start reviewing early. 3. Show what it takes to top the exam. Aim to be a board topnotcher. hindi naman oral exam and boards. It actually came as a complete shock to me. Just enjoy and have fun na. my initial reactions were of complete shock and disbelief. It has a little bit of everything in it. not because I didn’t prepare for the exams. RN (#2 November 2008 NLE) Topping the board exam was not something that I’d expected. When I finally got the news. Here it goes: 1. Therefore. Ayus na yun. Listen during lectures and study. Visualize yourself achieving that dream. Then rest when you get home. You have a lot of ground to cover and it may be difficult to be able to cover it completely but you have to cover as much ground as possible if you want to top the boards. the shock and disbelief abated. My journey towards taking the 2nd place in the November 2008 NLE started with a dream that I made in 3rd year college. Make a timetable. Kumanta ka hanggang sa mapaos. this article. Set a goal for yourself and work hard towards its achievement. So keep your anxiety on that level. Have the mindset. I could not believe the news. only an intense feeling of joy remained. months be a board topnotcher. you are left with heaps of notes and tons of books to read in your preparation for the board exam. When reviewing for a major exam. Kayang kaya mo yan! Madaming taong namemental block sa sobrang kaba. a feeling that I still have with me now. 2. Psych tells us that mild anxiety is normal and is indeed helpful. Prove yourself worthy. 3. Aim to be a board topnotcher and start from there. from the pathophysiology and medical management of medicine to the drug actions and interactions of pharmacy. but because I could not wrap myself around the idea that all my months of hard work have actually paid off and that I am exactly where I wanted to be right form the very beginning. How? By starting early. Don’t just dream of passing the board exam. 2. I always find myself unable to read all that I am supposed to read and I usually miss out on the more important concepts or . John Patrick Dimarucot. Kumanta ka hanggang sa mailabas mo lahat ng nerbiyos. It may seem impossible at first but.) Focus during the review. When I first received the news that I got the 2nd top spot in the Nursing Board Exams. If you’re going to dream.

Rationale: Normal urine output for an adult is approximately 1 ml/minute(60 ml/hour). redness. and therefore impede learning. I took it with God. Relax. This may result in hypokalemia. I asked His wisdom so I can understand all the concepts. A stat order is written for medications given immediately for an urgent client problem.e. 6.the concepts that I do not yet fully understand. You should do the same. Read! Read! Read! Need I say more? 5. a few of which are time management. 9. 12. I would usually coordinate my review with the schedule of the subjects in the review center. This is not something that just happened. also known as a protocol. This is the most important part. In the book is the Ultimate Success Planner where you can note down what subject you would want to review for the day and how much time you want to apportion for it. I found a solution to this predicament in Carl Balita’s Ultimate Learning Guide. then on weekends. This habit taught me a lot of competencies that I was able to apply when I took the board exams. Answer! Answer! Answer! Practice makes perfect. and increased warmth are signs of inflammation that shouldn'toccur after ice application 10. Beyond continuedevaluation. critical thinking. establishes guidelines for treating aparticular . andhyponatremia. I asked for His patience and strength when the review was taking its toll on me and I felt too tired to study. Higher levels of anxiety lead to diffusion of focus. Pray. Rationale: Functional nursing is focused on tasks and activities and noton the care of the patients. I can never stress enough the importance of relaxation and keeping your anxiety to a mild level. Rationale: Ice application decreases pain and swelling. Answer: (A) Provides continuous. I took it with God. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and. I would study subjects that I find hard (i. 7. sodium andpotassium. Fortunately. 4. Prescribers write a singleorder for medications given only once. hypovolemia. I would like to state a few things that we’ve learned in psychiatric Thinursing: Mild anxiety enhances learning. Continued or increasedpain. coordinated and comprehensivenursing services. 11. Community Health Nursing and Pediatric Nursing). Every step that I took in my preparation for the board exams. Answer: (B) ―My ankle feels warm‖. My being part of the roster of the topnotchers was something that I prayed really hard for and worked just as hard for. this client's output is normal. and test taking strategies. When I took the board exams. Answer :(A) Have condescending trust and confidence in their subordinates Rationale : Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. no nursing action is warranted. A standingorder. To emphasize my point. along with it. Therefore. 13. Answer: (B) Standard written order Rationale: This is a standard written order. I never would have made it here without His help.

These clients typically . Answer : (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult. Answer: (A) Provides continuous. Facilities also may institute medication protocols thatspecifically designate drugs that a nurse may not give. establishes guidelines for treating aparticular disease or set of symptoms in special care areas such as thecoronary care unit. also known as a protocol. A standingorder. A stat order is written for medications given immediately for an urgent client problem. sodium andpotassium. Beyond continuedevaluation. Rationale: Functional nursing is focused on tasks and activities and noton the care of the patients. hypovolemia. brown. 16. Prescribers write a singleorder for medications given only once.disease or set of symptoms in special care areas such as thecoronary care unit. coordinated and comprehensivenursing services. this client's output is normal. Answer: (A) Protect the irritated skin from sunlight. the nursegrasps the helix of the ear and pulls it up and back to straighten the ear canal. 9. Rationale: Normal urine output for an adult is approximately 1 ml/minute(60 ml/hour). 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) ―My ankle feels warm‖. Clientswith fecal impaction don't pass hard. andhyponatremia. formed stools because thefeces can't move past the impaction. the nurse grasps the helix and pulls it down tostraighten the ear canal. For a child. no nursing action is warranted. 15. Therefore. 12. 13. 11. Continued or increasedpain. formed stools because thefeces can't move past the impaction. Facilities also may institute medication protocols thatspecifically designate drugs that a nurse may not give. and increased warmth are signs of inflammation that shouldn'toccur after ice application 10. Clientswith fecal impaction don't pass hard. Answer: (B) Standard written order Rationale: This is a standard written order. Answer :(A) Have condescending trust and confidence in their subordinates Rationale : Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. redness. 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. Pulling the lobule in any direction wouldn'tstraighten the ear canal for visualization. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and. Rationale: Ice application decreases pain and swelling. along with it. 14. brown. This may result in hypokalemia. 14. These clients typically report the urgeto defecate (although they can't pass stool) and a decreased appetite.

and resistance to infection. 15. Answer: (B) Admit the client into a private room. The priority approach is the avoidance of strongsunlight. Answer: (D) Immobilize the leg before moving the client. Caloric goals may be ashigh as 5000 calories per day. Nail polishmust be removed so that cyanosis can be easily monitored by observingthe nail beds. and combs must be removed. Answer: (B) Place the client on the left side in the Trendelenburg position. Rationale: The client who has a radiation implant is placed in a privateroom and has a limited number of visitors. The nurse should call for emergency helpif the client is not hospitalized and call for a physician for the hospitalizedclient. Answer: (D) Sudden onset of continuous epigastric and back pain. Answer: (A) Protect the irritated skin from sunlight. the nursegrasps the helix of the ear and pulls it up and back to straighten the ear canal. Deficient knowledge related to the nature of thedisorder may be appropriate diagnosis but is not the priority. Answer: (A) Blood pressure and pulse rate. Answer : (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult. splinting the area beforemoving the client is imperative. 23. This reduces the exposure of others to the radiation. Answer: (B) Provide high-protein. Rationale: Dentures. 17. Rationale: Irradiated skin is very sensitive and must be protected withclothing or sunblock. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. 21.unrelieved epigastric or back pain reflects the inflammatory process in thepancreas. The Trendelenburg position .report the urgeto defecate (although they can't pass stool) and a decreased appetite. For a child. Rationale: The autodigestion of tissue by the pancreatic enzymes resultsin pain from inflammation. hairpins. 20. Rationale: If the nurse suspects a fracture. Theclient is at high risk for infection because of the decreased body defensesagainst microorganisms. Pulling the lobule in any direction wouldn'tstraighten the ear canal for visualization. 16. Rationale: A positive nitrogen balance is important for meeting metabolicneeds. and possible hemorrhage. Continuous. edema. 18. highcarbohydrate diet. 24. Rationale: Lying on the left side may prevent air from flowing into thepulmonary veins. 19. Answer: (C) Assist the client in removing dentures and nail polish. the nurse grasps the helix and pulls it down tostraighten the ear canal. tissue repair. 22. Rationale : The baseline must be established to recognize the signs of ananaphylactic or hemolytic reaction to the transfusion.

30.Postoperative pain is an indication of complication.and comparing the patient’s behavioral responses with the expectedoutcomes. Answer: (A) Take the proper equipment. Answer: (B) Assess the client for presence of pain. because only a 500 cc bag of solution isbeing medicated instead of a 1 liter. causing an increase inheart rate. Answer: (A) BP – 80/60.rapid and weak irregular pulse. Pulse – 110 irregular Rationale : The classic signs of cardiogenic shock are low blood pressure. Answer : (B)Evaluation Rationale: Evaluation includes observing the person. and it includes the basic ideas which are found in the other options 31. 32. and cerebral hypoxia. Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit.75 Rationale: . they will allowed to heal by secondaryintention 36. Answer : (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. cold. asking questions. and record the appropriate information in the client’s chart. place the client in a comfortableposition. The child is to receive 400 cc over a periodof 8 hours = 50 cc/hr. 35. The nurse should alsoassess the client for pain to provide for the client’s comfort. Answer: (A) Second intention healing Rationale: When wounds dehisce. 34. Answer: (A) 0.5 cc is to be added. 26. decreased urinaryoutput.increases intrathoracicpressure. provides resistance to theexternal rotation of the hip. Rationale: Assessing the client for pain is a very important measure. Answer: (C) History of present illness Rationale: The history of present illness is the single most importantfactor in assisting the health professional in arriving at a diagnosis or determining the person’s needs. Rationale: A trochanter roll. Answer : (C) Stage III Rationale: Clinically. 27. Answer : (D) 2. 37.5 cc Rationale : 2. clammy skin.compensatory mechanisms stimulate the heart. 29. which decreases the amount of blood pulled into the vena cavaduring aspiration 25. 28. Rationale: It is a general or comprehensive statement about the correctprocedure. properly placed. Answer: (A) Trochanter roll extending from the crest of the ileum to themidthigh. a deep crater or without undermining of adjacenttissue is noted. Answer: (A) Autocratic. 33. Rationale: The autocratic style of leadership is a task-oriented anddirective.

is one of the first signsof aging in middle life (ages 46 to 64). Answer: (B) 32 drops/minute Rationale: Giving 1.To determine the number of milliliters the client should receive.000 ml over 8 hours is the same as giving 125 mlover 1 hour (60 minutes). Rationale: Checking the client’s identification band is the safest way toverify a client’s identity because the band is assigned on admission andisn’t be removed at any time. The chest drainagesystem is kept lower to promote drainage – not to prevent leaks 42. it must be replaced).75 ml (or ¾ ml) = X 38. Answer: (A) Check the client’s identification band. and palpation. the nurse can place a sterile syringe or catheter plug in thecatheter hub. especially close vision. or 32 drops/minute 44. and palpation. 45. Increase in loss of muscletone occurs in later years (age 80 and older). percussion. Answer : (A) Clamp the catheter Rationale : If a central venous catheter becomes disconnected.75 mg/X ml = 100 mg/1 mlTo solve for X. of the hand to assestactile fremitus. Answer: (D) It’s a measure of effect. (If it is removed.1 ml/X gtt = 1 ml/ 15 gttX = 32 gtt/minute. auscultation. and vocal vibrations . Answer: (C) Failing eyesight. After cleaning the hub with alcohol or povidoneiodinesolution. 41. or ball. especially close vision.V.1 ml/minuteTo find the number of drops per minute:2. If a clamp isn’tavailable. thrills. extension and restart the infusion.8°C = 38. if available. Answer: (D) Auscultation. the nurseshould immediately apply a catheter clamp. Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isn’t secure. Rationale: An insulin unit is a measure of effect. not a standard measure of weight or quantity. Percussion and palpation can alter naturalfindings during auscultation. The reason for thisapproach is that the less intrusive techniques should be performed beforethe more intrusive techniques.the nurse uses the fraction method in the following equation. Checkingall connections and taping them will prevent air leaks. but isn’t the safe standard of practice. Find the number of milliliters per minute asfollows:125/60 minutes = X/1 minute60X = 125 = 2. oriented. not a standard measureof weight or quantity. Different drugs measured in units may have norelationship to one another in quality or quantity.9 °C Rationale: To convert Fahrenheit degreed to Centigrade. 39. percussion. More frequent aches and painsbegin in the early late years (ages 65 to 79). Answer: (B) 38.8°C = 70 ÷ 1.8°C = (102 – 32) ÷ 1. Rationale: Failing eyesight. Rationale: The correct order of assessment for examining the abdomen isinspection. Names on bedaren’t always reliable 43. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface. cross-multiply:75 mg x 1 ml = X ml x 100 mg75 = 100X75/100 = X0. 46. and able to understandwhat is being said. Askingthe client’s name or having the client repeated his name would beappropriate only for a client who’s alert.9 40. the nurse must replace the I. use this formula°C = (°F – 32) ÷ 1.

Answer: (A) Throbbing headache or dizziness Rationale : Headache and dizziness often occur when nitroglycerin istaken at the beginning of therapy. In respiratory alkalosis. Using a povidone-iodine wash and an antibiotic creamrequire a physician’s order. 49. lower thigh. One benefit is that thenurse can adjust teaching strategies as necessary to enhance learning. 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. causing hypokalemia. In this case. Hospice care doesn’t focus on counseling regarding healthcare costs. Answer: (B) To provide support for the client and family in coping withterminal illness. 50. 51. or knee does not promote venous return. Answer : (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuouslythroughout the teaching and learning process. Answer: (C) Using normal saline solution to clean the ulcer and applyinga protective dressing as necessary. 47. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area tothe proximal area. This method promotes venous return. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and anabove-normal partial pressure of arterial carbon dioxide (Paco2) value. The dorsalsurface best feels warmth. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to moveinto the cells. the pH and Hco3 values are above normal. thenurse should begin applying the bandage at the client’s foot. the pH and bicarbonate (Hco3) values are below normal. the client usually developstolerance 55. When a .indicating respiratory acidosis. Rationale: Hospices provide supportive care for terminally ill clients andtheir families. or past breast cancer. evaluation occurs at the conclusion of theteaching and learning session. Rationale: Washing the area with normal saline solution and applying aprotective dressing are within the nurse’s realm of interventions and willprotect the area. Thefingertips and finger pads best distinguish texture and shape. In metabolicacidosis. Massaging with an astringent can further damage the skin. Beginning atthe ankle.through the chest wall. 48. exist. If health risks.Summative. 53. or retrospective. Informative is not a type of evaluation. 52. However. Inmetabolic alkalosis. Answer: (D) Check the client’s level of consciousness Rationale: Determining unresponsiveness is the first step assessmentaction to take. genetic tendency. such as familyhistory. more frequentexaminations may be necessary. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in thehospice. the pH value isabove normal and in the Paco2 value is below normal. 54.

Low blood pressureand delayed capillary refill time are circulatory system indicators of inadequate perfusion. 60. Answer: (C) Secures the client safety belts after transferring to thestretcher. the nurse should stand on theaffected side and grasp the security belt in the midspine area of the smallof the back. Answer: (C) Use a sterile plastic container for obtaining the specimen. Rationale : When the client uses a walker. the nurse stands adjacent tothe affected side. Answer: (B) Cover the client.client is in ventricular tachycardia. Answer: (D ) Obtaining the specimen from the urinary drainage bag. Answer : (A) Urine output: 45 ml/hr Rationale : Adequate perfusion must be maintained to all vital organs inorder for the client to remain visible as an organ donor. which adverselyaffects all body tissues. The client is instructed to look up and outward rather than athis or her feet.32 is acidotic. the nursedraws one line through the incorrect information and then initials the error. Rationale : Sputum specimens for culture and sensitivity testing need tobe obtained using sterile techniques because the test is done to determinethe presence of organisms. Rationale: During the transfer of the client after the surgical procedure iscomplete. the nurse may needto answer it. Additionally. The other appropriate action is to ask another nurse to acceptthe call. However. 62.Urine undergoes chemical changes while sitting in the bag and does notnecessarily reflect the current client status. Answer: (A) Puts all the four points of the walker flat on the floor. Rationale: To correct an error documented in a medical record. To maintain privacy andsafety. Answer: (C) Draws one line to cross out the incorrect information andthen initials the change. 56. the nurse covers the client and places the call light within theclient’s reach. there is asignificant decrease in cardiac output. Hurried movements and rapid changes in theposition should be avoided because these predispose the client tohypotension. 61. then the specimen is not sterile. Rationale : A urine specimen is not taken from the urinary drainage bag. 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. 58. The nurse should position the free hand at the shoulder areaso that the client can be pulled toward the nurse in the event that there isa forward fall. Thiswill ensure client safety and prevent stress cracks in the walker. Rationale: When walking with clients. putsweight on the hand pieces. . place the call light within reach. then the specimen would becontaminated and the results of the test would be invalid. The clientis then instructed to move the walker forward and walk into it. and then walks into it. Rationale: Because telephone call is an emergency. A urine output of 45 ml per hour indicates adequate renal perfusion. is not one of the options. checking theunresponsiveness ensures whether the client is affected by the decreasedcardiac output.An error is never erased and correction fluid is never used in the medicalrecord. it may becomecontaminated with bacteria from opening the system. In addition. Answer: (B) On the affected side of the client. A serum pH of 7. the client’s door should be closed or the roomcurtains pulled around the bathing area. 57. However. and answer the phone call. If the procedure for obtaining the specimen isnot sterile. 59. the nurse should avoid exposure of the client because of therisk for potential heat loss. 63.

If the client is unable to sit up. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.therefore. 67. Goggles are not necessary unless thenurse anticipates the splashes of blood. 68.At the time of the transfer from the surgery table to thestretcher. the client should not move self. Answer: ( C) Primary source Rationale: This refers to a primary source which is a direct account of theinvestigation done by the investigator. Answer: (A) Descriptive. 74. the client is still affected by the effects of the anesthesia. 73. 71. 72. Safety belts can prevent theclient from falling off the stretcher. the clientis positioned lying in bed on the unaffected side with the head of the bedelevated 30 to 45 degrees. Shoe protectors are not necessary. Answer: ( C) Res ipsa loquitor Rationale : Res ipsa loquitor literally means the thing speaks for itself.This means in operational . Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. 70. Answer: ( A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any actionthat will cause any harm to the patient/client. To do good is referred asbeneficence. Answer : (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret willensure anonymity because this will hinder providing link between theinformation given to whoever is its source. Answer : (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a clientwith weakness on one side. which is written by someone other than the original researcher . 66. A cane is better suited for client withweakness of the arm and leg on one side. However. body fluids. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. secretions.correlational study is the most appropriate for thisstudy because it studies the variables that could be the antecedents of theincreased incidence of nosocomial infection. hencelaboratory data is essential. 69. In contrast to this is a secondarysource. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through theuse of biophysiologic measures.correlational Rationale: Descriptive. Rationale : To facilitate removal of fluid from the chest wall. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. or excretions may occur. It refers tothe repeatability of the instrument in extracting the same responses uponits repeated administration. 64. particularly in vitro measurements. the quad cane wouldprovide the most stability because of the structure of the cane andbecause a quad cane has four legs. 65. the client ispositioned sitting at the edge of the bed leaning over the bedside tablewith the feet supported on a stool.

76. 80. b) at least four years has elapsed since the license hasbeen revoked. subpoena or subpoena duces tecum as needed. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem. It resulted to an increasedproductivity but not due to the intervention but due to the psychologicaleffects of being observed. 85. 82. 79. The action of allowing the patient to decide whether a surgery is tobe . a revokedlicense maybe re-issued provided that the following conditions are met: a)the cause for revocation of license has already been corrected or removed. Answer: (B) Determines the different nationality of patients frequentlyadmitted and decides to get representations samples from each. Answer: (B)Madeleine Leininger Rationale : Madeleine Leininger developed the theory on transculturaltheory based on her observations on the behavior of selected peoplewithin a culture. theresearcher conducts a review of related literature to determine the extentof what has been done on the study by previous researchers. Answer: ( A) Random Rationale : Random sampling gives equal chance for all the elements inthe population to be picked as part of the sample. self-concept mode.terms that the injury caused is the proof thatthere was a negligent act. Rationale : Judgment sampling involves including samples according tothe knowledge of the investigator about the participants in the study. 77. 24 states that for equity and justice. Answer: (B) Hawthorne effect Rationale : Hawthorne effect is based on the study of Elton Mayo andcompany about the effect of an intervention done to improve the workingconditions of the workers on their productivity. Answer: (C) May apply for re-issuance of his/her license based on certainconditions stipulated in RA 9173 Rationale: RA 9173 sec. 81. Answer: (A) Degree of agreement and disagreement Rationale : Likert scale is a 5-point summated scale used to determine thedegree of agreement or disagreement of the respondents to a statementin a study 83. role function mode anddependence mode. including the risks involved and the alternativesolutions. 84. Answer: (B)Sr. Callista Roy developed the Adaptation Model whichinvolves the physiologic mode. Answer : (B) The Board can investigate violations of the nursing law andcode of ethics Rationale: Quasi-judicial power means that the Board of Nursing has theauthority to investigate violations of the nursing law and can issuesummons. Answer : (A) Span of control Rationale : Span of control refers to the number of workers who reportdirectly to a manager. They performed differently because they wereunder observation. and. In giving consent it is done with full knowledge and is givenfreely. 75. Callista Roy Rationale: Sr. 78. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understandsabout the surgery.

Administering an already-prescribed drug on time is adependent intervention. The findings show that the expected outcomes havebeen achieved. 86.although appropriate when preparing to administer a blood transfusion.Implementation is the phase of the nursing process where the nurse putsthe plan of care into action. Analysis consists of consideringassessment information to derive the appropriate nursing diagnosis. 87. Answer: (A) Arrange for typing and cross matching of the client’s blood. Rationale: The nurse first arranges for typing and cross matching of theclient's blood to ensure compatibility with donor blood. swelling.come later.Assessmentconsists of the client's history.Oranges and broccoli supply vitamin C but not protein. If the client can't assumethis position nor has poor sphincter control. Answer : (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of theexpected outcomes. 88. Both cotton and cornstarch absorb perspiration. An intradependent nursing intervention doesn'texist. The supine and prone positions areinappropriate and uncomfortable for the client. Ice cream suppliesonly some incomplete protein.The client should be instructed to cut toenails straight across with nailclippers. the leg muscles can stillstretch and relax. 90. cause skinirritation and breakdown. or dyspnea. Rationale: The client should be instructed to avoid wearing canvas shoes. When the stockings are in place. which thisclient needs to repair the tissue breakdown caused by pressure ulcers.Canvas shoes cause the feet to perspire.done or not exemplifies the bioethical principle of autonomy. The other options. Applying the stockings increases bloodflow to the heart. Signs and symptoms of lifethreatening allergicreactions include . Thenurse needs to remove them once per day to observe the condition of theskin underneath the stockings. Answer: (D) Sims’ left lateral Rationale: The Sims' left lateral position is the most common positionused to administer a cleansing enema because it allows gravity to aid theflow of fluid along the curve of the sigmoid colon. 91. Answer: (A) Instructing the client to report any itching. physicalexamination. and laboratory studies. which may. making it less helpful in tissue repair. Answer: (C) Avoid wearing canvas shoes. in turn. 93. Rationale : Because administration of blood or blood products may causeserious adverse effects such as allergic reactions. whereasconsulting with the physician and pharmacist to change a client'smedication because of adverse reactions represents an interdependentintervention. Answer: (D) Ground beef patties Rationale : Meat is an excellent source of complete protein.interdependent. the nurse must monitor the client for these effects. Altering the drug schedule to coincide withthe client's daily routine represents an independent intervention. Answer: (A) Independent Rationale : Nursing interventions are classified as independent. the dorsal recumbent or rightlateral position may be used. and the veins can fill with blood. or dependent. 89. 92.

and dyspnea.The nurse should apply the face mask from the client's nose down to thechin — not vice versa. and oxygen intake. these actions are less critical to the client'simmediate health. Rationale: Measuring the blood drug concentration helps determinewhether the dosing has achieved the therapeutic goal.which helps dissolve the medication. The nurse should check the connectors betweenthe oxygen equipment and humidifier to ensure that they're airtight. Rationale: By assisting the client to the semi-Fowler position. 100. to prevent bacterialgrowth. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between1 and 4 hours.Feedings are normally given at room temperature to minimize abdominalcramping. peak blood drug levels typically aredrawn after administering the next dose. swelling. according to facilitypolicy. Answer: (D) Roll the vial gently between the palms. anabnormal finding.itching. breathing. Answer : (B) Immediately before administering the next dose. Answer : (B) Decrease the rate of feedings and the concentration of theformula. or lowest. . Also. Rationale: Rolling the vial gently between the palms produces heat. the nursepromotes easier chest expansion. It shouldn't infuse for longer than 4 hours because the riskof contamination and sepsis increases after that time. 97. Answer: (C) Shifting dullness over the abdomen. The other options are normal abdominal findings. Doing nothing or inverting the vialwouldn't help dissolve the medication. Shaking the vial vigorously couldcause the medication to break down.loosened connectors can cause loss of oxygen. Thenurse should secure the elastic band so that the face mask fitscomfortably and snugly rather than tightly. which could lead to irritation. Depending on thedrug's duration of action and halflife. 98. 99. Decreasing the rate of the feeding andthe concentration of the formula should decrease the client's discomfort. 94. blood level of a drug. Rationale: A floor stock system enables the nurse to implementmedication orders quickly. altering its action. It doesn't allow for pharmacist input. Rationale: Shifting dullness over the abdomen indicates ascites. the nurse draws a bloodsample immediately before administering the next dose. The nurse should assess vital signs at least hourlyduring the transfusion. Although the nurseshould inform the client of the duration of the transfusion and shoulddocument its administration. For measurementof the trough. 96. To prevent aspiration during feeding. feeding containers should be routinely changed every 8 to 12hours. Rationale : Complaints of abdominal discomfort and nausea are commonin clients receiving tube feedings. Discard or return tothe blood bank any blood not given within this time. TEST IIAnswers and Rationale – Community Health Nursing and Care of theMother and Child 1. Answer: (B) Assist the client to the semiFowler position if possible. nor does itminimize transcription errors or reinforce accurate calculations. 95. the head of the client'sbed should be elevated at least 30 degrees. Answer: (A) The nurse can implement medication orders quickly.

Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis. but insulin does not. isindicative of hyperstimulation of the uterus. the best approach is to talkto the mother and ignore the toddler first.Fetal activity would not be noted. 2. 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. Rationale: Contractions every 1 ½ minutes lasting 7080 seconds. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds. An elevated pulse rate is an indicator of shock. 12. This approach helps the toddler get used to the nurse before she attempts any procedures. Answer : (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy isfocused on preventing or identifying hypovolemic shock and controllingpain. 3. and early development of pregnancyinduced hypertension. 10.Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannotbe prevented. . Rationale : The most common signs and symptoms of hydatidiform moleincludes elevated levels of human chorionic gonadotropin. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy. Rationale: Fetus at station plus two indicates that the presenting part is 2cm below the plane of the ischial spines. It also givesthe toddler an opportunity to see that the mother trusts the nurse. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration iscardiac arrest. vaginalbleeding. High fetaldemands for glucose. larger than normal uterus for gestational age. Moderate to severe bleeding with mild cramping andcervical dilation would be noted in this type of abortion. Answer : (D) First low transverse caesarean was for breech position. failure to detectfetal heart activity even with sensitive instruments. 6. Answer: (A) Excessive fetal activity. Continuous monitoring of cardiac activity (EKG) throughtadministration of calcium gluconate is an essential part of care. toxoplasmosis. 7.Fetus in this pregnancy is in a vertex presentation. Rationale: When dealing with a crying toddler. 11. 4. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. which could result in injury tothe mother and the fetus if Pitocin is not discontinued. Rationale : This type of client has no obstetrical indication for a caesareansection as she did with her first caesarean delivery. which requires administration of calcium gluconate. andrubella are causes of spontaneous abortion. Answer : (B) Increased caloric intake Rationale: Glucose crosses the placenta. combined with the insulin resistance caused byhormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. 8. 5. 9. excessive nausea andvomiting. Answer : (D) Place the infant’s arms in soft elbow restraints.

000. Answer : (A) Mayor Rationale: The local executive serves as the chairman of the MunicipalHealth Board. Answer : (B) Allow the infant to rest before feeding. Answer: .Rationale : Soft restraints from the upper arm to the wrist prevent theinfant from touching her lip but allow him to hold a favorite item such as ablanket. infants can sit securelyalone but cannot understand the permanence of objects. 19. even baby food until age 6months. 22. such as objectsas pacifiers. 4 is on the Ligtas TigdasProgram. and small spoons shouldn’t be placed in ababy’s mouth after cleft repair.infants can’t sit securely alone. Answer: (D) Core group formation Rationale : In core group formation. The public health nurse is an employee of the LGU. Rationale: Because feeding requires so much energy. At age 8 months. Answer: (C) Iron-rich formula only. 7160 devolved basic health services to local governmentunits (LGU’s ). Answer: (D) Public health nursing focuses on preventive.A. the nurse is able to transfer thetechnology of community organizing to the potential or informal communityleaders through a training program. The suture lineshould be cleaned gently to prevent infection. Rationale : The catchments area in PHN consists of a residential community. Answer: (B)Measles Rationale : Presidential Proclamation No. A baby in a prone position may rub her face on the sheets and traumatize the operative site. At age 4 to 6 months. 14. 13. 20. which could interfere withhealing and damage the cosmetic appearance of the repair. an infant with heartfailure should rest before feeding. Answer: ( A) 1 Rationale : Each rural health midwife is given a population assignment of about 5. many of whom are well individuals who have greater need for preventive rather than curative services. 18. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. 15. Answer: (D) Rural Health Unit Rationale: Because they could damage the operative site. suction catheters. Answer: (D) 10 months Rationale : A 10 month old infant can sit alone and understands objectpermanence. Answer: (B) Health education and community organizing are necessary inproviding community health services. so he would look for the hidden toy. 24. 17. 21. 23. not curative. Answer: (B) Efficiency Rationale: Efficiency is determining whether the goals were attained atthe least possible cost. Rationale: The infants at age 5 months should receive iron-rich formulaand that they shouldn’t receive solid food. 16.

complicated cases and the terminally ill (those in the terminalstage of a disease). 29. 25. B and C are objectives of contributory objectives tothis goal. Answer: (A) Change the diaper more often. Answer: (D) Terminal Rationale : Tertiary prevention involves rehabilitation. abruptio placentae. 28. with thegoal of developing the people’s selfreliance in dealing with communityhealth problems. Rationale: Decreasing the amount of time the skin comes contact withwet soiled diapers will help heal the irritation. 30. and premature rupture of the membranes aren't associated withDIC. . Answer : (B) Decreased urine output Rationale : Decreased urine output may occur in clients receiving I. if clottingfactors are depleted. Answer: (D) Endocardial cushion defect Rationale : Endocardial cushion defects are seen most in children withDown syndrome. 35. Answer: (C) 120 to 160 beats/minute Rationale : A rate of 120 to 160 beats/minute in the fetal heart appropriatefor filling the heart with blood and pumping it out to the system. Approximately 40% of a woman’s cardiac output is delivered tothe uterus. Rationale : The infant with the airway emergency should be treated first. blood loss can occur quite rapidly in the event of uncontrolled bleeding.V. asplenia. DIC may occur. A.magnesium and should be monitored closely to keep urine output atgreater than 30 ml/hour. Placenta accreta. therefore. 34. 26. 27. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancyas the increase in plasma volume exceeds the increase in red blood cellproduction. 36. Rationale: Community organizing is a developmental service. septic shock. 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 deliveryprocess. sitting up inhis mother’s arms and drooling. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. 32. Rationale: Intrauterine fetal death. 33. 31. Answer: (D) A 2 year old infant with stridorous breath sounds.the disabled. andamniotic fluid embolism may trigger normal clotting mechanisms. prevention of permanent disability and disability limitation appropriate for convalescents. Answer: ( A) Intrauterine fetal death.because of the risk of epiglottitis.(D) To maximize the community’s resources in dealing withhealth problems. dysfunctionallabor. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. because magnesium is excreted through thekidneys and can easily accumulate to toxic levels. or polysplenia.

The rationale for thistiming is that. thespecimen should be collected early in the morning. the nursemust first check that the client’s kidneys are functioning and that the client is voiding. butthe flow will be slow enough not to overload the stomach too rapidly. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test. to any client. such aspallor or cyanosis. If the client is not voiding. the nurse should withhold thepotassium and notify the physician. Answer: (D) Voided Rationale: Before administering potassium I. 37. 43.V. andlearning disabilities. The topical allergen that is the most common causativefactor is laundry detergent. 39. the diaphragm should be insertedbefore every intercourse. Latesigns of hypoxia in a child are associated with a change in color. although the ―fertile‖ periodis approximately mid-cycle. To be effective. 42. Answer : (C) More oxygen. Answer : (A) Loud. the infant requires more oxygen and there is anincrease in metabolic rate. the first bowel movement of the day will yield the bestresults. 46. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity. therefore. Answer: (D) ―I really need to use the diaphragm and jelly most during themiddle of my menstrual cycle‖. hyperactivity. Answe r: (B) Walk one step ahead. the more susceptible he becomes to thecomplications of chicken pox. 41. Answer: (c) Laundry detergent Rationale : Eczema or dermatitis is an allergic skin reaction caused by anoffending allergen. machinery-like murmur. the newborn increase heat production. Answer: (A) Irritability and seizures Rationale : Lead poisoning primarily affects the CNS. 40. Non-shievering thermogenesis is a complexprocess that increases the metabolic rate and rate of oxygenconsumption. Rationale : This procedure is generally recommended to follow in guidinga person who is blind. Answer: (C) Restlessness Rationale : In a child. restlessness is the earliest sign of hypoxia. Rationale: The woman must understand that. Answer: (A) The older one gets. as well as seizure disorders. because the female worm lays eggs at night around theperineal area. machinery-like murmur is a characteristic findingassociated with patent ductus arteriosus. hormonal variations do occur and can result inearly or late ovulation. Rationale : When cold. causing increasedintracranial pressure. 38. and the newborn’s metabolic rate increases.Answer : (D) Early in the morning Rationale : Based on the nurse’s knowledge of microbiology. 45. with the child’s hand on the nurse’selbow. 44. Rationale . Rational e: A loud. This condition results in irritability and changes inlevel of consciousness.

Rationale : Rubella vaccine is made up of attenuated German measlesviruses. like rats. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. referral to a facility where IV fluidscan be initiated within 30 minutes. Answer: (B) Severe dehydration Rationale : The order of priority in the management of severe dehydrationis as follows: intravenous fluid therapy. but age distribution isnot specific in young children. therefore. Answer: (A) 45 infants Rationale: To estimate the number of infants. This is contraindicated in pregnancy. suchas sexually transmitted diseases. may be given to pregnant women. Both amebic and bacillary dysentery are characterized by thepresence of blood and/or mucus in the stools. Streptococcus pneumoniaeand Neisseria meningitidis may cause meningitis. 53. 50. Morbillivirus is the etiology of measles. MMR is not an immunization in theExpanded Program on Immunization. Answer : (B)Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. 52. Answer : (A) Contact tracing Rationale : Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections. 54. Answer: (B) Buccal mucosa Rationale: Koplik’s spot may be seen on the mucosa of the mouth or thethroat.Complications. 51. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. When theforegoing measures are not possible or effective. such as pneumonia. The appropriate storagetemperature of DPT is 2 to 8° C only. Indeveloping countries. Immune globulin.: Chicken pox is usually more severe in adults than in children. Cutting the cycle at this stage is the . 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. 57. Giardiasis is characterizedby fat malabsorption and. Oresol or nasogastric tube. OPV and measles vaccine are highlysensitive to heat and require freezing. Answer: (D) Consult a physician who may give them rubellaimmunoglobulin. 48. Answer : (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of thecolor of the nailbed within 3 seconds. 56. then urgent referral tothe hospital is done. the peak incidence is in children less than 6 monthsof age. multiply total population by3%. a specificprophylactic against German measles. 47. Answer : (A) DPT Rationale : DPT is sensitive to freezing. steatorrhea. 55. are higher in incidence in adults. 49.

68.vomiting is managed by letting the child rest for 10 minutes and thencontinuing with Oresol administration. Rationale: ―Baggy pants‖ is a sign of severe marasmus. the first question to determinemalaria risk is where the client’s family resides. 65. Rationale : If the child vomits persistently.most effective way of preventing the spread of the disease to susceptible hosts. 64. Teach the mother to give Oresolmore slowly. Answer: (B) Some dehydration Rationale : Using the assessment guidelines of IMCI. 63. Answer : (B) Ask where the family resides. This is why BCG immunization is scheduled only in themorning. Answer: . a respiratory rate of 50/minute or more is fastbreathing for an infant aged 2 to 12 months. 60. that is. The bestmanagement is urgent referral to a hospital. Otherwise. 61. Inability to close the eyelids(lagophthalmos) and sinking of the nosebridge are late symptoms. Answer : (A) Refer the child urgently to a hospital for confinement. Answer: (D) 5 skin lesions. Answer : (A) Inability to drink Rationale: A sick child aged 2 months to 5 years must be referredurgently to a hospital if he/she has one or more of the following signs: notable to feed or drink. Answer : (D) Let the child rest for 10 minutes then continue giving Oresolmore slowly. positive slit skin smear Rationale : A multibacillary leprosy case is one who has a positive slit skinsmear and at least 5 skin lesions. It is characterized by achange in skin color (either reddish or whitish) and loss of sensation. 59. a child (2 months to5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable. If the area of residence isnot a known endemic area. convulsions. 67. abnormally sleepy or difficult to awaken. 5 doses will give the mother lifetime protection. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may begiven until the end of the day. Rationale: Because malaria is endemic. The mother will have active artificial immunitylasting for about 10 years. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. only BCG is discarded 4 hours after reconstitution. Answer : (C) Normal Rationale : In IMCI. 62. ask if the child had traveled within the past 6months. 66. sunkeneyes. where she was brought and whether she stayed overnight in thatarea. he vomits everythingthat he takes in. the skin goes back slow after a skin pinch.sweating and hair growth over the lesion. 58. Answer : (A) 1 year Rationale: The baby will have passive natural immunity by placentaltransfer of antibodies. he has to be referred urgently to a hospital. vomits everything.

Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation) 70. Answer: (B) Sudden infant death syndrome (SIDS) Rationale : Supine positioning is recommended to reduce the risk of SIDSi n i n fa n c y. especially when it results in a lowtemperature in the neonate.for . Suffocation would be less likely with an infant supine than proneand the position for GER requires the head of the bed to be elevated. T h es e n eo nat es ar e u su al l y v er y al er t . Th e n eo nat e w i t h a n i n f e cti o n wi l l usu al l y s ho w a decrease in activity level or lethargy. The neonate would befloppy. Answer: (C) Respiratory depression Rationale : Magnesium sulfate crosses the placenta and adverse neonataleffects are respiratory depression. Answer: (C) Decreased temperature Rationale: Temperature instability. The neonate’scolor often changes with an infection process but generally becomesash e n or m ottl e d. the baby’s nutrient needs. and the epidermisma y b e c om e d es qu am at e d . Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa. The serumblood sugar isn’t affected by magnesium sulfate. may be a sign of infection.g est at i o n n e on ate i s at r i sk for d e vel o pi n g polycythemia during the transitional period in an attempt to decreaseh y p o x i a . and bradycardia. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale : T he s mal l . the lungs aredeveloped enough to sometimes maintain extrauterine life. not jittery. Answer: (C) Respiratory rate 40 to 60 breaths/minute . 73. especially thebaby’s iron requirement. Answer: (C ) 24 weeks Rationale: At approximately 23 to 24 weeks’ gestation. 75. 69. The lungs arethe most immature system during the gestation period. 74. hypotonia. The r i sk o f as pi r a t i o n i s sl i gh tl y i n cr e ase d wi t h t he s u pi n e position.(B) 6 months Rationale: After 6 months. T h e neonates are also at increased risk for d e v e l o p i n g hypoglycemia and hypothermia due to decreased glycogen stores. Lanugo is missing in the postdate neonate. 72. 71. can no longer be provided by mother’s milkalone.

and support persons. Answer : (B) Conjunctival hemorrhage Rationale : Conjunctival hemorrhages are commonly seen in neonatessecondary to the cranial pressure applied during the birth process. Willingness to touch and hold the n e w b o r n . Fetalwell-being is assessed via a nonstress test.Rationale: A r e spi r ator y r at e 4 0 t o 6 0 b r e ath s /mi n ut e i s nor mal f or a neonate during the transitional period. respiratory rate morethan 60 breaths/minute. Gravidity and parity affect the duration of labor and the potential for labor complications. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infectionand hastens drying. Answer: (B) Instructing the client to use two or more peripads to cushionthe area Rationale: Using two or more peripads would do little to reduce the painor promote perineal healing. 77. 78. Infants aren’t given tub bath but are sponged off untilt he c or d f al l s of f . Bulgingfontanelles are a sign of intracranial pressure. 80. expressing interest about the newborn's size. sitz baths. Fetal position is determinedby vaginal examination. the nurse should askabout chronic illnesses. Cold applications. Rationale: Parental interaction will provide the nurse with a g o o d assessment of the stability of the family's home life but it has no indicationf o r p a r e n t a l bonding. Nasal flaring. and Kegelexercises are important measures when the client has a fourthdegreelaceration. Simian creases are presentin 40% of the neonates with trisomy 21. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe. Cystic hygroma is a neck massthat can affect the airway. Peroxide could be painful and isn’t recommended. Rationale: The nurse's first action should be to clear the neonate's airwayw i t h a . 76. gravidity. and indicating a desire tosee the newborn are behaviors indicating parental bonding. Artificial rupture of membranes doesn't indicate animminent delivery. particularly her due date. thenurse's highest priority is to determine her current status. and parity. 81. allergies.The most effective way to do this is to check the fetal heart rate. 82. Later. and audible grunting are signs of respiratorydistress. Answer: (C) ―What is your expected due date?‖ Rationale: When obtaining the history of a client who may be in labor. 79. Answer : (D) The parents’ interactions with each other. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy. the nurse should assure thatthe cord isn't prolapsed and that the baby tolerated the procedure well. P etr ol e um j el l y p r e ve nts t he c or d fr o m d r yi n g a nd encourages infection.

the nurse shouldnotify the physician. Answer : (C) Monitor partial pressure of oxygen (Pao2) levels. checkingvaginal discharge with nitrazine paper. A ft er t he ai r w ay i s c l ear an d t he n e on ate ' s c ol or improves. then twins don’t’ gain weight as rapidly assingletons of the same gestational age. The placenta can no longer keeppace with the nutritional requirements of both fetuses after 32 weeks. 87. Cleavage thatoccurs less than 3 day after fertilization results in diamniotic dicchorionictwins. The recommended calorie requirement is110 to 130 calories per kg of newborn body weight. Covering the infant's eyes and humidifying the oxygen don't reduce therisk of retinopathy of prematurity. Rationale: Monitoring PaO 2 levels and the reducing k ee p P aO 2 w i t hi n n or mal l i mi ts r ed u c es th e r i sk of r e t i n o p a t h y o f prematurity in a premature infant r e c e i v i n g o x y g e n . 85. If the problemrecurs or the neonate's color doesn't improve readily. Cleavage that occurs between days 8 to 13 result o x y g e n c on c e ntr ati on t o . Observing for pooling of strawcolored fluid. Because cooling increases the risk of acidosis. the infant should be kept warm so that his respiratory distressisn't aggravated. sothere’s some growth retardation in twins if they remain in utero at 38 to 40weeks. 84. Answer: (A) 110 to 130 calories per kg.b ul b s yr i ng e . Answer : (C) Conducting a bedside ultrasound for an amniotic fluid index Rationale: I t i sn 't wi thi n a n ur s e 's s c op e o f pr a cti ce t o p er for m an di nt er pr e t a b e dsi d e ul tr as ou n d u n d er t he se c on di ti o ns and wi t h out specialized training. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’ gestation. Rationale: Calories per kg is the accepted way of determined appropriatenutritional intake for a newborn. 83. Administering oxygen when the airway isn't clear would be ineffective. and observing for flakes of vernixar e a p pr o pr i ate a sse ssm e nts f or d e t er m i ni n g wh et her a c l i en t ha s ruptured membranes. the nurse should comfort and calm the neonate. This level will maintaina consistent blood glucose level and provide enough calories f o r continued growth and development. Cleavage inconjoined twins occurs more than 13 days after fertilization. Answer: (A) conjoined twins Rationale: T h e t yp e o f pl ac e nt a t hat d e vel o ps i n m o noz yg ot i c t w i ns depends on the time at which cleavage of the ovum occurs. Cleavage that occurs between days 3 and 8 results in diamnioticmonochorionic twins. 86.

93. Tenmilliliters of 10% calcium gluconate is given L. 88. Answer: (D) Ultrasound Rationale: O n c e th e mo th er a nd t h e f et us ar e st abi l i z e d . 91.V. Antihypertensived r u g o t h e r than magnesium are preferred for sustained h y p e r t e n s i o n . Antihypertensive drugs usually aren’t necessary.Hydralazine is given for sustained elevated blood pressure in preeclampticc l i e n t s . Thei n c r e a s e d oxygen consumption in the pregnant client i s 1 5 % t o 2 0 % greater than in the nonpregnant state. Answer: . R h o ( D ) immune globulin is given to women with Rhnegativeb l o o d t o prevent antibody formation from RHpositive c o n c e p t i o n s . Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper.V. Long-acting insulin usually isn’t needed for blood glucose control in the client with gestational diabetes. T h e inspiratory capacity increases during pregnancy. although it will detect fetal distress. A digital or sp ec u l um e xami na ti o n sh o ul dn ’ t b e d o n e as th i s ma y l ea d t o s ev er e bleeding or hemorrhage. Diuretic wouldn’t be usedunless fluid overload resulted. Amniocentesis is contraindicated in placenta previa. u l tr as o un d evaluation of the placenta should be done to determine the cause of thebleeding. Magnesium doesn’t help prevent hemorrhage in preeclamptic clients. which increases the tidalvolume of gas moved in and out of the respiratory tract with each breath.inmonoamniotic monochorionic twins. Naloxone is used to correct narcotic toxicity. Fluids. The client usually needs as t r o n g e r a n a l g e s i c t h a n acetaminophen to control the pain of a c r i s i s . push over 3 to 5 minutes. which may result from bloodloss or placenta separation. Answer : (A) Diet Rationale : Clients with gestational diabetes are usually managed by dieta l o n e t o c o n t r o l t h e i r glucose intolerance. 90. Oral hypoglycemic drugs a r e contraindicated in pregnancy. A n s w er: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. 92.V. 94.Hypomagnesemia isn’t a complication of preeclampsia.The expiratory volume and residual volume decrease as the pregnancyp r o g r e s s e s . External fetal monitoring won’t detect a placentaprevia. 89. fluids Rationale: A sickle cell crisis during pregnancy is usually m a n a g e d b y exchange transfusion oxygen. and L. Answer : (C) I. Answer : (D)Seizure Rationale: The anticonvulsant mechanism of magnesium is believes todepress seizure foci in the brain and peripheral neuromuscular blockade.

urgency. leading to maternal hypotension and. Lethargy isn't associated with neonatal heroinaddiction.and suprapubic tenderness. small eyes. 100. 98.enhances comfort. The standing position a l s o t a k e s advantage of gravity and aligns the fetus with the pelvic angle. For instance. a serious conditionin a pregnant client. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis. stimulating maternal antibodies.(B) An indurated wheal over 10 mm in diameter appears in 48 to72 hours. The area must be a raisedwheal. reduces muscle tension.the lateral. In subsequent pregnancies with Rh-positive fetuses. 99. not a flat circumcised area to be considered positive. Bacterial vaginosis causes milky white vaginal discharge butno systemic symptoms. This is known as subinvolution. Answer: .The other positions promote comfort and aid labor progress. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aortaan d i n f er i or v en a cava b y t h e f etu s. increases maternal relaxation. p o or sucking. 96. and thin lips are seen in infantswith fetal alcohol syndrome. position improves maternal and fetal circulation. Heroin use during pregnancy hasn't beenlinked to specific congenital anomalies. Thi s. Rationale : A positive PPD result would be an indurated w h e a l o v e r 1 0 mm in diameter that appears in 48 to 72 hours. UTI symptoms include dysuria. and restlessness. or side-lying. Answer: (A) 7 th to 9 th day postpartum Rationale: T h e n or mal i nv ol u t i o nal p r o c ess r et ur ns t h e u t er us t o t h e pelvic cavity in 7 to 9 days. Asymptomatic bacteriuria doesn’t causesymptoms. ultimately. Answer: (B) Irritability and poor sucking. frequency.and eliminates pressure points. Rationale: Neonates of heroinaddicted mothers are p h y s i c a l l y dependent on the drug and experience withdrawal when the drug is nol on g er su p pl i e d . Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cellscr oss i nto t h e mat er nal c i r c ul ati on a n d sti mu l at e m at er nal a nt i bo d y production. 97. 95. fetal hypoxia. A significant involutional complication is thefailure of the uterus to return to the pelvic cavity within the prescribed timeperiod. S i g ns o f her oi n wi th dr aw al i n cl u d e i r r i ta bi l i ty . maternalantibodies may cross back into the fetal circulation and destroy the fetalblood cells. i nhi bi t s mat er n al circulation. A flattened nose. Answer: (B) Rh-positive fetal blood crosses into m a t e r n a l b l o o d . The squatting position promotes comfortb y t a k i n g advantage of gravity. i n tur n.

by pulling the emergency callbutton. Answer : (C) Check respirations. bloody Rationale : Normal bowel function and softformed stool usually do notoccur until around the seventh day following surgery. Answer: (C) Loose. so the heart does not have to work hard. Rationale: The significant effect of nitroglycerin is vasodilation anddecreased venous return. the therapeutic level is 1. Answer: (D) Decreasing venous return through vasodilation. 3. and check circulation Rationale : Checking the airway would be priority. or will neutralize and buffer the acid that doesaccumulate. Rationale . Rationale : Having established. 8. andexcoriated. 4. Answer: (A) On the client’s right side Rationale : The client has left visual field blindness. andtraumatic delivery commonly are associated with uterine atony. Noting the time is important baseline information for cardiac arrestprocedure. 5. of if the phone is not available. Answer: (B) Continue treatment as ordered. The client will see onlyfrom the right side. stabilize spine. Answer : (B) In the operating room. that the client isunconscious rather than sleep. 6. 9.(B) Uterine atony Rationale: Multiple fetuses. extended labor stimulation with oxytocin. the nurse should immediately call for help. and a neck injury shouldbe suspected. Rationale : The effects of heparin are monitored by the PTT is normally 30to 45 seconds. Skin exposed to these enzymes even for a short time becomes reddened. 7. TEST IIIAnswers and Rationale – Care of Clients with Physiologic andPsychosocial Alterations 1. which maylead to postpartum hemorrhage.5 to 2 times the normal level.Drainage from the ileostomy contains secretions that are rich in digestiveenzymes and highly irritating to the skin. Rationale : Food and drug therapy will prevent the accumulation of hydrochloric acid. Rationale: The stoma drainage bag is applied in the operating room. painful. The stoolconsistency is related to how much water is being absorbed. Answer : (C) Make sure that the client takes food and medications atprescribed intervals. Uterine inversion may precede or followdelivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually.This may be done by dialing the operator from the client’s phone andgiving the hospital code for cardiac arrest and the client’s room number tothe operator. by stimulating the client. Protection of the skin from theeffects of these enzymes is begun at once. Answer : (B) Flat on back. Uterineinvolution and some uterine discomfort are normal after delivery. 2. Answer: (A) Call for help and note the time.

13. cough. 14. and an increased in residual volume 16. but isn’tusual.which avoids trauma to the neurons. but elderly clients may firstappear with only an altered lentil status and dehydration due to a bluntedimmune response. Answer : (B) Avoid foods high in vitamin K Rationale: The client should avoid consuming large amounts of vitamin Kbecause vitamin K can interfere with anticoagulation. 17. bloodpressure. It’s unlikely the client will have asthma attack or a seizure or wake up on his own.and hemoptysis. Aspirin may increase the risk of bleeding. Nausea. night sweats. Clients with TB typically have lowgrade fevers. 11. Answer: (B) Respiratory arrest Rationale : Narcotics can cause respiratory arrest if given in largequantities. Answer: (D) Decreased vital capacity Rationale : Reduction in vital capacity is a normal physiologic changesinclude decreased elastic recoil of the lungs. acetaminophen shouldbe used to pain relief. dyspnea. headache. acute asthma isthe most likely diagnosis. Answer : (C) Clipping the hair in the area Rationale : Hair can be a source of infection and should be removed byclipping. 18. the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Answer :(A) Acute asthma Rationale : Based on the client’s history and symptoms. Rationale: Lidocaine drips are commonly used to treat clients whosearrhythmias haven’t been controlled with oral medication and who arehaving PVCs that are visible on the cardiac monitor. Rationale: This finding suggest that the level of consciousness isdecreasing.: To avoid the complication of a painful spinal headache that canlast for several days. fever. and pleuritic chestpain are the common symptoms of pneumonia. and ICP are important factors but aren’t as significant as PVCsin the situation. and photophobia aren’t usual TBsymptoms. Answer: (B) Chills.By keeping the client flat. The client may needto report diarrhea. 12. An electricrazor-not a straight razorshould be used to prevent cuts that causebleeding. 10. not higher than102°F (38. Headaches are believed tobe causes by the seepage of cerebral spinal fluid from the puncture site. Answer: (C) The client is oriented when aroused from sleep. Answer . chills. and hemoptysis Rationale: Typical signs and symptoms are chills. 19. Chest pain may be present from coughing. cerebral spinal fluid pressures are equalized. but isn’t effect of taking an anticoagulant. 15.9°C). fewer functional capillaries inthe alveoli. Answer: (A) Altered mental status and dehydration Rationale: Fever. fever. He’s unlikely to have bronchial pneumoniawithout a productive cough and fever and he’s too young to havedeveloped (COPD) and emphysema. hemortysis. Answer: (C) Presence of premature ventricular contractions (PVCs) on acardiac monitor. SaO2. night sweats. and goesback to sleep immediately. Shaving the area can cause skin abrasions and depilatories canirritate the skin.

andcoughing harshly because these activities increase intraocular pressure. Dowager’s hump results from bone fractures. Answer: (C) Balance the client’s periods of activity and rest. Rationale : The client should be encouraged to increase his activity level. so the nurse should never try toclose it.hemorrhoidectomy is an outpatient procedure. 21.Typically. and avoiding stress are all important factors in decreasing the risk of atherosclerosis. 24. Rationale: A client with hyperthyroidism needs to be encouraged tobalance periods of activity and rest. But a negative calcium balance isn’t a complication of osteoporosis.: (A) Bone fracture Rationale : Bone fracture is a major complication of osteoporosis thatresults when loss of calcium and phosphate increased the fragility of bones. preferably when he enters his teens. Answer: (B) Place a saline-soaked sterile dressing on the wound. 20. lifting heavy objects. 22. instruct the client when lying in bed to lie on either the side or back.Maintaining an ideal weight. 25. such as laminectomy.must be log rolled to keep the spinal column straight when turning. 27. Many clients with hyperthyroidism arehyperactive and complain of feeling very warm. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods. areas of thickness or fullness that signal thepresence of a malignancy. Rationale: The nurse should first place salinesoaked sterile dressings onthe open wound to prevent tissue drying and possible infection. Rationale : The client should avoid straining. Then thenurse should call the physician and take the client’s vital signs. Estrogen deficiencies result from menopause-not osteoporosis. Answer : (B) Increase his activity level. Under normal circumstances.Thoracotomy and cystectomy may turn themselves or may be assistedinto a comfortable position. Answe r: (C) Changes from previous examinations. The client should avoid bright light by wearingsunglasses. A male client should be taught how to perform testicular self-examination before age 20. Rationale: . Thedehiscence needs to be surgically closed. It developswhen repeated vertebral fractures increase spinal curvature. Answer: (D) Before age 20. Answer: (D) Avoiding straining during bowel movement or bending at thewaist. low sodium diet. 26. the client is instructed to avoid lifting objects weighing more than15 lb (7kg) – not 5lb. following a lowcholesterol. or masses that are fibrocystic as opposed tomalignant. Answer : (A) Laminectomy Rationale: The client who has had spinal surgery. 23. Only a physician can diagnoselumps that are cancerous. Rationale : Women are instructed to examine themselves to discover changes that have occurred in the breast.Calcium and vitamin D supplements may be used to support normal bonemetabolism. Rationale: Testicular cancer commonly occurs in men between ages 20and 30. and the client may resumenormal activities immediately after surgery.

Infection and excessive drainage won’t cause atension pneumothorax. 33. with the head of thebed lowered. Insertion can break the teeth and lead to aspiration. Marital status information may be important for dischargeplanning but is not as significant for addressing the immediate medicalproblem. 29. Crackles do not replacewheezes during an acute asthma attack. however. wheezing may stop and breath soundsbecome inaudible because the airways are so swollen that air can’t getthrough. thenurse should perform the abdominal thrust maneuver with the clientstanding. he should be able to dislodge theobject or cause a complete obstruction. 30.Cheyne-Strokes respirations are breaths that becomeprogressively deeper fallowed by shallower respirations with apneasperiods. 28. deep breathing without pauses. Excessive water won’t affect the chest tubedrainage. Coarse crackles are caused by secretion accumulationin the airways. If the attack is over and swelling has decreased. Rationale : During the active seizure phase. General health in the previous 10 years is important. Tracheal breath sounds are auscultatedover the trachea. Biot’s respirations are rapid. Answer : (B) Kinked or obstructed chest tube Rationales : Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. If complete obstruction occurs. thecurrent activities of an 84 year old client are most significant in planningcare. If the client is unconscious. A nurseshould never leave a choking client alone. A small amount of toothpaste should be used and the mouth swabbed or suctioned . Kussmaul’srespirationa are rapid. and equal depth between each breath. 34. Answer : (C) Place the client in a side lying position. remove dangerous objects. removing dangerous objects. Answer : (D) Stay with him but not intervene at this time. Friction rubs occur with pleural inflammation. Answer: (B) Fine crackles Rationale : Fine crackles are caused by fluid in the alveoli and commonlyoccur in clients with heart failure. Family history of disease for a client in later years is of minor significance. Answer: (B) The airways are so swollen that no air cannot get through Rationale : During an acute attack. 31. 32. A bite block should never be inserted during the activeseizure phase. and protecting hishead from injury. initiate precautions by placingthe client on his side. Tachypnea isshallow breathing with increased respiratory rate. Answer: (B) Current health promotion activities Rationale: Recognizing an individual’s positive health measures is veryuseful. Rationale: If the client is coughing. Rationale: The client should be positioned in a side-lying position with thehead of the bed lowered to prevent aspiration. there would beno more wheezing and less emergent concern. Answer: (D) Place the client on his side. andprotect his head. she should lay him down. deep breathing with abrupt pausesbetween each breath.

and corticosteroids.are at extremely high risk for developing TB. 40. the chest X-ray will show their presence in the lungs. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism Rationale: Clients who are economically disadvantaged. Client with ARDShave acute symptoms of hypoxia and typically need large amounts of oxygen. 43. such as a client with a history of alcoholism. 35. . 41. Beta-adrenergic blockers aren’t used to treat asthma and can cause bronchoconstriction. 37. malnourished. Sputum culture confirms the diagnosis. A chest X-ray can’tdetermine if this is a primary or secondary infection. the client with TBtypically has a cough producing blood-tinged sputum. During the transplant. There canbe false-positive and falsenegative skin test results.Pleuritic chest pain varies with respiration. the patient is administered with drugsthat would help to prevent infection and rejection of the transplanted cellssuch as antibiotics. Lemon glycerin can be drying if used for extended periods. if not treated aggressively. 39. Answer: (C) Chronic obstructive bronchitis Rationale : Because of this extensive smoking history and symptoms theclient most likely has chronic obstructive bronchitis. Hydrogen peroxide is caustic to tissues and should not beused. Clients with asthma and emphysema tend not to have chroniccough or peripheral edema. Brushing the teeth with the client lying supine may leadto aspiration. A sputum cultureshould be obtained to confirm the nurse’s suspicions. day-care worker. Answer: (C) Pneumonia Rationale : Fever productive cough and pleuritic chest pain are commonsigns and symptoms of pneumonia. cytotoxic. Theinitial action of the nurse should be raising the side rails to ensure patientssafety. A high school student. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first line of treatment for asthmabecause bronchoconstriction is the cause of reduced airflow. Answer: (A) Crowd red blood cells Rationale : The excessive production of white blood cells crowd out redblood cells production which causes anemia to occur. so this client most likely isn’t having an MI. 38.and have reduced immunity. and businessman probably have a much low risk of contracting TB. 42. Answer: (A) The patient is under local anesthesiaduring the procedure Rationale : Before the procedure. The client with ARDS has dyspneaand hypoxia with worsening hypoxia over time. Answer : (D) Raise the side rails Rationale : A patient who is disoriented is at risk of falling out of bed.the patient is placed under general anesthesia.toremove pooled secretions. Answer: (C ) To determine the extent of lesions Rationale : If the lesions are large enough. 36. unlike the constant chest painduring an MI. Answer : (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CLL) is characterized byincreased production of leukocytes and lymphocytes resulting inleukocytosis. Inhaled oral steroids may be given to reduce the inflammationbut aren’t used for emergency relief.

No evidence .spleen and liver. Answer : (C) Radiation Rationale: The usual treatment for vaginal cancer is e x t e r n a l o r intravaginal radiation therapy. surgery is p e r f o r m e d . B ar bi tur at e o ver d os e ma y tr i gge r r es pi r at or y d epr es si o n a n d sl ow p ul s e .and proliferation of these cells within the bone marrow. 49. Answer: (A) Explain the risks of not having the surgery Rationale: The best initial response is to explain the risks of not havingthe surgery. Less often. dilitiazem (Cardizem) Rationale : The client with atrial fibrillation has the greatest potential tobecome unstable and is on L. Cocaine i n c r e a s e s myocardial oxygen consumption and can cause coronary artery spasm. 45. myocardial ischemia. 46. Immunotherapy isn't used to treat vaginalcancer.leading to tachycardia. Answer : (B) Nonmobile mass with irregular edges Rationale: Breast cancer tumors are fixed. M0 denotes carcinoma in situ.who requires timeconsuming supportive measures. O pi o i d s c a n c a us e mar k ed r es pi r at or y depression. andno evidence of distant metastasis Rationale: TIS. If the client understands the risks but still refuses the nurseshould notify the physician and the nurse supervisor and then record theclient’s refusal in the nurses’ notes. and no evidence of distant metastasis. hard.A ft er a sse ssi n g thi s cl i e nt. while benzodiazepines can cause drowsiness and confusion. andm yo car d i al i nf ar c ti o n . and poorly delineatedwith irregular edges. and then the 58y e ar . Th e lowest priority is the 89-year-old with endstage right-sided heart failure. 47.V. Answer: (D) The 75-year-old client who was admitted 1 hour ago withnew-onset atrial fibrillation and is receiving L.V. 44. Answer: (B) Carcinoma in situ. Answer: (C) Cocaine Rationale: Because of the client’s age and negative medical history. th e n ur s e s ho ul d ass es s t he c l i en t wi th thrombophlebitis who is receiving a heparin infusion. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed inan early stage.ol d cl i en t a dmi t te d 2 d a ys a go wi th he ar t f ai l ur e ( hi s si gns an ds ym pto ms ar e r e sol vi n g a nd do n ’t r eq ui r e i mm e di at e at t e nti on ). which is rare. N0. no abnormal regionallymph nodes. Axillary lymph nodes may or may notbe palpable on initial detection of a cancerous mass. A mobile mass that is soft and easily delineated ismost often a fluid-filled benign cyst. ventricular fibrillation. then u r s e s h o u l d q u e s t i o n her about cocaine use. medication that requires close monitoring. Nipple retraction —not eversion — may be a sign of cancer 48. no abnormal regional lymph nodes.

of primary tumor. A progressive increase in tumor size. lymphoma. 50. thelesion is classified as TX. Answer: (B) Lung cancer Rationale: Lung cancer is the most deadly type of cancer in both womenand men. Answer: (D) "Remain supine for the time specified by the physician. Local anesthetics used in a subarachnoidblock don't alter the gag reflex. partial eyelid ptosis.because a dry stoma may become irritated. Arm and shoulder pain and atrophy of the arm andh an d m us cl es on t h e a ff e ct e d si de s u gg est P a n coa st 's t umor . Rationale: PSA stands for prostatespecific antigen. followed (in descendingorder) by colon and rectal cancer. liver cancer. 54. leukemia. Breast cancer ranks second in women. NX. ovarian cancer. N0. Answer: (C) Sigmoidoscopy . stomachcancer. partial eyelid ptosis. which is u s e d t o screen for prostate cancer. N0. cough. and multiple myeloma.uterine cancer. and anhidrosis on the affected side of theface. which occurs when a lung tumor invadesthe ribs and affects the sympathetic nerve ganglia. 51. and fever are associatedwith pleural tumors. brain cancer. is characterized bymiosis. and anhidrosis on the affectedside of the face." Rationale: The nurse should instruct the client to remain supine for thetime specified by the physician. and ascendingdegrees of distant metastasis is classified as T1. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve. Rationale: Horner's syndrome. 53. If the tumor and regionallymph nodes can't be assessed and no evidence of metastasis exists. andM1. no abnormal regional lymph nodes. and no evidence of distant metastasis is classified as demonstrable metastasis of the regional lymph nodes. weight loss. pancreatic cancer. which is used to screen for prostatecancer. 55.such as by applying a thin layer of petroleum jelly around the edges." Rationale: The nurse should instruct the client to keep the stoma moist. dysphagia suggeststhat the lung tumor is compressing the esophagus. M0. Answer: (D) "Keep the stoma moist. or M3. or T4. dyspnea. Chest pain. Answer: (A) miosis. T2. T h e client should begin performing stoma care withoutassistance as soon as possible to gain independence in selfc a r e activities. Answer: (A) prostate-specific antigen. M0. The other answers are incorrect. M2. No interactions between local anestheticsand food occur. T3. Local anesthetics don't cause hematuria. 52. The nurse should recommendplacing a stoma bib over the stoma to filter and warm air before it enterst h e s t o m a . a l un g tumor involving the first thoracic and eighth cervical nerves within thebrachial plexus.

because the strong magnetic field can pull on them. however. 56. not acontraindication. Rationale: Premenopausal women require 1. Many women have slightlya s y m m e t r i c a l breasts. Strenuous exercise won't cause fractures. Answer: (D) The client wears a watch and wedding band. bone. Rationale: During an MRI. suchas jewelry.500 mg per day. Answer : (A) Liver Rationale: The liver is one of the five most common cancer metastasissites. lung. 58.reproductive tract. Bloody nipple discharge is a sign of i n t r a d u c t a l papilloma. the client should wear no metal objects. round. Joint deformity and . Multiple firm. It's often. Osteoporosis doesn't show up on ordinary Xrays until 30% of the boneloss has occurred. a benign condition. and WBCs are occasional metastasis sites. which are caused by the sound waves thumping on the magneticfield. sigmoidoscopy a n d proctoscopy aid in the detection of twothirds of all colorectal cancers. 59. Answer : (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying s k i n i s common during late stages of breast cancer. though notalways. 60. the test doesn't confirm the diagnosis. The client must lie stillduring the MRI but can talk to those performing the test by w a y o f t h e microphone inside the scanner tunnel. a benigncondition.000 mg of calcium per day. Answer : (C) The recommended daily allowance of calcium may be foundin a wide variety of foods. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients w i t h j o i n t f l e x i o n o f less than 50% because of technical problems in inserting the instrumenti n t o t h e j o i n t t o see it clearly. causingi n j u r y t o t h e c l i e n t and (if they fly off) to others. which is a sign of colorectal c a n c e r . Joint pain may be an indication. The colon. The others are the lymph nodes. possible to get the recommended daily requirement in the foodsw e a v a i l a b l e e a t . CEA may be elevated incolorectal cancer but isn't considered a confirming test. Bone densitometry can detect bone loss of 3% or less. and brain.S t o o l H e m a t e s t detects blood. The client should hear thumpingsounds. freely movable massesthat change with the menstrual cycle indicate fibrocystic breasts. 57. for arthroscopy.Rationale: Used to visualize the lower GI tract. An abdominal CTscan is used to stage the presence of colorectal cancer. a r e b u t S u p p l e m e n t s n o t a l w a y s n e c e s s a r y . Other contraindications for this p r o c e d u r e include skin and wound infections.Postmenopausal women require 1.This test is sometimes recommended routinely for women over 35 whoare at risk.

Answer: (D) Gouty arthritis Rationale: Gouty arthritis. but rheumatoid arthritis is. especially in the knees. benign condition marked by r e g u l a r .joint stiffness aren'tcontraindications for this procedure. 64. DVT may develop in clients with as t r o k e b u t i s more likely to occur in the lower extremities. Answer: (B) It appears on the distal interphalangeal joint Rationale: Heberden’s nodes appear on the distal interphalageal joint onb o t h m e n a n d women. especially those in the feet and legs. 62.000 units of heparin in 500 ml of s a l i n e s o l u t i o n y i e l d s 50 units of heparin per milliliter of solution. Answer: (B) Loss of muscle contraction decreasing venous return Rationale : In clients with hemiplegia or hemiparesis loss of musclecontraction decreases venous return and may cause s w e l l i n g o f t h e affected extremity. walker. 67. their use takes weight and stress off joints. Answer: (B) 30 ml/hou Rationale: An infusion prepared with 25. Osteoarthritis isn’t gender-specific. 63.I n t e r m i t t e n t arthritis is a rare. or bony calcifications may occur with astroke. Traumatic arthritis results from blunt trauma to a joint or ligament. a correct substitution requires mixing 21 U of NPH and9 U of regular insulin. 9 U regular insulin and 21 U neutral protamine Hagedorn(NPH). Uratedeposits don't occur in septic or traumatic arthritis. Rationale: A 7 0 /3 0 i n sul i n p r e par a t i o n i s 7 0 % N P H a n d 3 0 % r e g ul ar insulin. A s t r o k e i s n ’ t linked to protein loss. . a metabolic disease. but don’t appear with swelling. Therefore. Contractures. A client withosteoarthritis should be encouraged to ambulate with a cane. X equals 30 ml/hour. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis issystemic Rationale: Osteoarthritis is a localized disease. or other assistive device as needed.500units/hour. The other choices are incorrect dosages for theprescribed insulin. Bouchard’s node appears on the d o r s o l a t e r a l aspect of the proximal interphalangeal joint 65. rheumatoid arthritis is systemic. 61. Answer: (A) a. recurrent joint effusions. Answer : (C) The cane should be used on the unaffected side Rationale: A cane should be used on the unaffected side. Septic arthritis resultsfrom bacterial invasion of a joint and leads to inflammation of the synoviallining. T h e equation is set up as 50 units times X (the unknown quantity) equals 1. 66. is characterized by uratedeposits and pain in the joints.Clients have dislocations and subluxations in both disorders.

68. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation (especially inthe great toe). Administering fluids by any route would further increase the client's already heightened fluid load.Furosemide. This hormone acts on the renalt u b ul e . Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency. gout is caused by urate crystal deposits in the joints. Dry sterile dressings protect the wound frommechanical trauma and promote healing. BUN increases as the glomerular filtrationr a t e reduced. not totreat gout. Answer : (C) They debride the wound and promote healing by secondaryintention Rationale: F or t h i s cl i e nt . c a u s i n g hypoglycemia. Reduced cortisol secretion leads to impaired glyconeogenesisa n d r e d u c t i o n g l y c o g e n t h e l i v e r m u s c l e . Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH. thus promoting healing by secondary intention. t h e nurse should restrict fluids. Answer: (D) glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches o f i n a n d a . 71. Thephysician prescribes colchicine to reduce these deposits and thus ease joint inflammation. it isn'tindicated for gout because it has no effect on urate crystal formation.dr y d r e ssi ng s ar e mos t a p pr o pr i at e be ca us e t he y c l ea n th e f oot ul c er b y d e br i di ng ex ud at e an d n e cr o ti ctissue. Moist. a diuretic. The pancreas mainly secretes hormonesi n v o l v e d in fuel metabolism. transparentdr essi n gs c o nta i n exu da te a nd p r ov i d e a m oi st w ou n d e nv i r o nm ent . 73. Answer : (A) Adrenal cortex Rationale: Excessive secretion of aldosterone in the adrenal cortex isresponsible for the client's hypertension. Calcium gluconate is used toreverse a negative calcium balance and relieve muscle cramps. we t .H y dr o co l l oi d d r e ssi ng s pr ev en t t h e e ntr an c e o f mi cr oor ga ni s ms a nd minimize wound discomfort. 72. The parathyroidssecrete parathyroid hormone. is Hyponatremia caused by is reduced a l d o s t e r o n e secretion. The adrenal medulla secretes t h e catecholamines — epinephrine and norepinephrine. 69. Although aspirin is used to reduce joint inflammationand pain in clients with osteoarthritis and rheumatoid arthritis. 70.t o. the client has hyperkalemia due t o reduced aldosterone secretion. doesn't relieve gout. w her e i t p r om ot es r e ab sor pti on of s o di u m an d e x cr eti o n o f potassium and hydrogen ions.

the client is at greatest risk for hypoglycemia from 3 p. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hoursa f t e r administration. and diarrhea may signal acquired immunodeficiencys y n d r o m e (AIDS).mineralocorticoids. it is helpful in monitoring cancer treatment because the levelu s u a l l y f a l l s t o normal within 1 j u s t o n e f r o m r e c o v e r i n g month if treatment is successful. s u r g e r y . Anelevated acid phosphatase level may indicate prostate cancer. A n elevated alkaline phosphatase level may reflect bone metastasis. rash. Signs and symptoms of hypocalcemiam a y be delayed for up to 7 days after surgery.m.and pallor as well as fatigue. Answer: (A) Hypocalcemia Rationale: Hypocalcemia may follow thyroid surgery if the p a r a t h y r o i d glands were removed accidentally. Therefore. Serum fructosaminelevels provide information about blood glucose control over the past 2 to 3weeks.m. potassium. glycosylated hemoglobin levels provide i n f o r m a t i o n about blood glucose levels during the previous 3 months. H y p e r k a l e m i a . listlessness. 78. 74. A n elevated serum calcitonin level usually signals thyroid cancer. Answer : (A) Glucocorticoids and androgens Rationale: The have the adrenal two cortex glands divisions.n o t t h y r o i d a n d hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium. Thyroid surgery doesn'tdirectly cause serum sodium. 76. fluid therapy. Nightsweats. 77. 75. and anorexia may be signs o f hepatitis B. Answer : (D) Carcinoembryonic antigen level Rationale: In clients who smoke. it can't be used as a general indicator of cancer. and androgens. and pallor Rationale: Signs of iron-deficiency anemia include dyspnea. and jaundice may result from an allergic o r hemolytic reaction.tosome of the hemoglobin and stays attached during the 120day life spano f r e d b l o o d cells. tachycardia. Answer : (B) Dyspnea. or magnesium a b n o r m a l i t i e s . tachycardia.. The medulla produces catecholamines— epinephrine and norepinephrine. Fasting bloodg l u c o s e a n d u r i n e glucose levels only give information about g l u c o s e levels at the point in time when they were obtained. irritability. vomiting. a n d medulla.however. Hyponatremia may occur if the client inadvertently received too much fluid. this can happen to any surgical client receiving I. and headache.V. Itching.However. Nausea. to 7 p. weight loss. the level of carcinoembryonic antigen ise l e v a t e d . The cortex produces three types of hormones: glucocorticoids.m. not thyroid surgery. Because the nurse administered N P H i n s u l i n a t 7 a.

Rationale: Prolonged use of aspirin and other salicylates sometimescauses bilateral hearing loss of 30 to 40 decibels. the nurse first s h o u l d a d mi n i st er e pi n ep hr i ne . utensils. i s m o s t concentrated in the blood. tachycardia. and paresthesia of the hands andfeet. 81. Th e physician is likely to order additional medications. and a sore tongue are all characteristicf i n d i n g s i n pernicious anemia. Bradycardia. angina. No antidote for penicillin exists.palpitations. however. A client who remainshypotensive may need fluid resuscitation and fluid intake and outputmonitoring. which c a u s e s AIDS. t h e c l i e n t shouldn't share personal articles that may be bloodcontaminated. such as antihistaminesand corticosteroids. the nurse should prepare tointubate the client. such astoothbrushes and razors." Rationale: The human immunodeficiency virus (HIV)." Rationale: Thehuman immunodeficiency virus (HIV)is transmitted fromm o t h e r t o c h i l d via the transplacental route. tachycardia. as pr es cr i b ed . with other family members. weight loss. a n d pr ep ar e t o intubate the client if necessary. 80. and double visionaren't characteristic findings in pernicious anemia 82. a p ot en t b r o n ch o di l at or as p r e scr i b e d. Large or toxic salicylatedoses may cause respiratory alkalosis. Answer: (D) "I'll need to have a C-section if I become pregnant and havea baby. 83. not respiratory acidosis. Usually. or serving dishes used by aperson with AIDS. fatigue. For this r e a s o n . Answer: (C) "Avoid sharing such articles as toothbrushes and razors. but a Cesarean s e c t i o n delivery isn't necessary when the mother is HIV-positive. however. administering epinephrine is the first priority. Other clinical manifestations i n c l u d e anorexia.79. HIV isn't transmittedby bathing or by eating from plates. . Answer: ( B ) A dmi ni st er e pi n ep hr i ne . Answer: (D) bilateral hearing loss. reduced pulse pressure. Aspirindoesn't lead to weight gain or fine motor tremors. It's truet h a t a mother who's HIV positive can give birth to a baby who's H I V negative. beefy red tongue. and a sore tongue Rationale: Pallor. weight gain. this adverseeffect resolves within 2 weeks after the therapy is discontinued. Rationale: To reverse anaphylactic shock. weakness. 84. The use of birthcontrol will prevent the conception of a child who might have HIV. a wide pulse pressure. if these medications don't relieve the respiratorycompromise associated with anaphylaxis. Answer: (B) Pallor. the nurseshould continue to monitor the client's vital signs. a smooth.

difficile. Answer : (C) stool for Clostridium difficile test. 85. Answer: (A) moisture replacement. nose. The neutrophil is crucial to phagocytosis. An electrolyte panel and overallevaluation of a client but causes of diarrhea. clients receivingchemotherapy. it isn't the predominant problem. Rationale: Sjogren's syndromei s a n a ut oi mm un e di sor de r l ea di ng t o progressive loss of lubrication of the skin. Rational e: HIV 87. ears.A da pti v e i mm un i t y i s m e di at e d b y B a nd T l ym ph o c yte s an d can b e acquired actively or passively.T h e ba sop hi l p l a ys a n i m por t ant r o l e i n t he r el eas e o f i nfl amma tor ym e di at or s. S u c ce ss ful tr eat me nt b e gi ns wi t h a n a c c u r a t e diagnosis. T h e mo no c yt e f un c t i on s i n p h ag o cy tos i s a nd m on ok i ne production.Answer: (D) Lymphocyte Rationale: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. 86. Arrhythmias aren't aproblem associated with Sjogren's syndrome. which includes a stool test. Answer: infection is (D) Western detected blot test by analyzin inthis case. GI tract. and vagina. which causes" hor s e bar n " s mel l i n g di ar r hea . T h e E L I S A t e s t i s diagnostic for human immunodeficiency virus (HIV) and isn't indicated hemogram may be useful in the aren't diagnostic for specific the abdomen may provide useful information about with ELISA. Rationale: Immunosuppressed clients — for example.Moisture replacement is the mainstay of therapy.A flat plate of bowelfunction but isn't indicated in the case of "horse barn" smelling diarrhea . Though malnutrition andelectrolyte imbalance may occur as a result of Sjogren's syndrome's effecton the GI tract. — are at risk for infection with C.

which form approxi mately 2 to 12 weeks after exposure to HIV anddeno te infection .g blood for antibodi es toHIV. The Western blot test — electrop horesis of antibody proteins — is more than 98% accurate in detecting HIV antibodi es whenuse d in conjunct ion with .

It isn't specific when used alone.the ELISA. Erosette immunof luoresce nce is used to detect viruses in general. it doesn'tc onfirm HIV inf ection. Quantifi cation o f Tlympho cytes is a useful monitori ng test but isn't diagnost ic for HIV. The ELISA test detects HIVanti body particles .

but may yield inaccurat e results; a positive ELISA resultmu st be confirme

d by the Western blot test. 88. Answer: (C) Abn ormally low hem atocrit ( HCT) an

d hemog lobin (H b)levels Rational e: Low preopera tive HCT and Hb

levels indicate the client mayrequ ire a blo od trans fusion b efore su rgery. If the HC

T and H b levels decrease during surgery because of blood loss, the potential need for

atransfus ion increases . Possible renal failure is indicated by elevated

BUNor creatini ne level s. Urine constit uents ar en't fou nd in th e blood. Coagulat

ion is determ ined by the presence of appro priate clotting factors,n ot

electrolyt es. 89. Answer: (A) Platelet count, prothro mbin time,

and partial thrombo plastinti me Rational e: The diagnosi s of DIC

is based on the results of laborato rystudie s of prot hrombin time, pl atelet co

unt, thr ombin ti me, part ialthrom boplastin time, and fibrinoge n level as well as client

history and other ass essment factors. Blood glucose levels, WBC count,

calcium levels, andpotas sium levels aren't used to confirm a

diagnosis of DIC. 90. Answer: (D) Strawber ries Rational e:

Commo n food allergens include berries, peanuts, Brazil nuts,cash ews, shellfish,

and eggs. Bread, carrots, and oranges rarely causealle rgic

reactions . 91. Answer: (B) A client with cast on the right leg who

states, ―I have a funnyfee ling in my right leg.‖ Rational e: It may indicate

neurovas cular compro mise, requires immediat eassessm ent. 92. Answer

: (D) A 62-yearold who had an abdomin alperineal resection threeday s ago;

client complain ts of chills. Rational e : The client is at risk for

peritonit is; should be assessed for furth er symptom s and infection.

93. Answer : (C) The client spontane ously flexes his wrist when

the bloodpre ssure is obtained. Rational e: Carpal spasms indicate

hypocalc emia. 94. Answer: (D) Use comfort measures and pillows to

position the client. Rational e: Using comfort measure s and pillows

to position the client is anonpharmac ological methods of pain relief. 95.

Answer: (B) Warm the dialysate solution. Rational e: Cold dialysate

increases discomf ort. The solution should bewarm ed to bo dy temp erature i n warm

er or he ating pa d; don‘t usemicr owave oven. 96. Answer: (C) The client

holds the cane with his left hand, moves the caneforw ard followed

by the right leg, and then moves the left leg. Rational e: The cane acts as a

support and aids in weight bearing for theweak er right leg. 97.

Answer: (A) Ask the woman‘s family to provide personal items such asphotos

or memento s. Rational e: Photos and mement os provide

visual stimulati on to reducese nsory deprivati on. 98. Answer:

(B) The client lifts the walker, moves it forward 10 inches, andthen takes

several small steps forward. Rational e: A walker needs to be picked

up, placed down on all legs. 99. Answer: (C) Isolation from their

families and familiar surround ings. Rational e: Gradual loss of sight,

hearing, and taste interfere s with normalfu nctioning . 100. Answer:

(A) Encoura ge the client to perform pursed lip breathing .

Rational e: Purse lip breathing prevents the collapse of lung unit and helpsclie

nt control rate and depth of breathing TEST IVAnsw ers and Rati onale –

Care of Clients with Ph ysiologic andPsyc hosocial Alterati ons 1. Answer:

(C) Hyperten sion Rational e: Hyperte nsion, al ong wit h fever, and tend

erness o ver theg rafted kidney, reflects acute rejection. 2. Answer: (A) Pain

Rational e : Sharp, severe pain (renal colic) radiating toward the

genitalia and thigh is caused by uretheral distentio n and smooth muscle

spasm;re lief form pain is the priority. 3. Answer: (D) Decrease the size

and vasculari ty of the thyroid gland. Rational e: Lugol‘s solution provides

iodine, which aids in decreasi ng thevascu larity of the thyroid gland,

which limits the risk of hemorrh age whensur gery is performe d.

4. Answer: (A) Liver Disease Rational e: The clie nt with l iver dis ease has

a decre ased abi lity tom etabolize carbohyd rates because of a decrease d ability

to form glycogen (glycoge nesis) and to form glucose from glycogen .

5. Answer: (C) Leukope nia Rational e : Leuko penia, a reductio

n in WB Cs, is a systemic effect o f chemot herapy as a result of myelosu

ppressio n. 6. Answer: (C) Avoid foods that in the past

caused flatus. Rational e : Foods that bothered a person preoperat ively will

continue to doso after a colostom y. 7. Answer: (B) Keep the irrigatin

g containe r less than 18 inches above thestoma .‖ Rational e:

This height permits the solution to flow slowly with little forceso

Answer: (A) Administ er Kayexala te Rational e: Kayexal ate. 9. 8.a potassiu m exchang e resin. permits sodium to beexc hanged for potassiu m in the intestine. reducing the serum potassiu mlevel. Answer: .that excessiv e peristalsi s is not immediat ely precipitat ed.

multiply the amount to be infused(2 000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 10. Answer: (D) Upper trunk Rational e: The percenta ge designat .(B) 28 gtt/min Rational e: This is the correct flow rate.

Answer: (C) .ed for each burned part of the bodyusin g the rule of nines: Head and neck 9%. Posterior trunk 18%. Perineu m 1%. 11. Leftuppe r extremit y 9%. Right upper extremit y 9%. Left lower extremit y 18%. Anterior trunk 18%. Right lower ex tremity 18%.

Bleeding from ears Rationa le: The nurse needs to perform a thorough assessme nt that couldindi cate alteration s in cerebral function. Bleeding from the ears occurs only with basal skullfract ures that can easily contribut e to increased intracran ial . increased intracran ial pressures .fractures and bleeding.

Answer : (A) Oxygen at 12L/min is given . This will prevent trauma to the area of the pacemak er generator . 13. Answer: (D) may engage in contact sports Rationa le: The client should be advised by the nurse to avoid contactsp orts.pressure andbrain herniatio n. 12.

The hypoxic stateof the client then becomes the stimulus for breathing .to maintain the hypoxic stimulusf or breathing . Giving the clientoxy gen in low . Rational e: COPD causes a chronic CO2 retention that renders themedul la insensiti ve to the CO2 stimulati on for breathing .

Rationa le: Since only a partial pneumon ectomy is done. 14. Answer: (B) Facilitate ventilatio n of the left lung.concentr ations will maintain the client‘s hypoxic drive. Answer: . 15. there is a needto promote expansio n of this remainin g Left lung by positioni ng the clienton the opposite unoperat ed side.

the doctors sprays the back of thethroat with anestheti c to minimize the gag reflex and thus facilitate theinserti on of the bronchos cope.(A) Food and fluids will be withheld for at least 2 hours. Giving the client food and drink after theproce dure without checking on the . Rationa le: Prior to bronchos copy.

The gag reflex usually returns after two hours. Theadmi . Rational e: Hyperkal emia is a common complica tion of acute renal failure.It' s lifethreateni ng if immediat e action isn't taken to reverse it. 16. Answer: (C) hyperkal emia.return of the gag reflex can cause theclient to aspirate.

Hy pernatre mia.nistration of glucose and regular insulin. and hypercal cemia don't usually occur withacut e renal failure . hypokale mia. can temporar ily prevent cardiac arrest by moving potassiu minto the cells and temporar ily reducing serum potassiu m levels. with sodium bicarbon ate if necess ary.

Rationa le: Women with condylo . Answer : (A) This conditio n puts her at a higher risk for cervical cancer. 17. she should have a Papanic olaou (Pap) smear annually . insulin. or sodiumbi carbonat e.and aren't treated with glucose.t herefore .

Becaus e condy lomata acumin ata is a virus. t here is noperm anent cure. Because condylo mata acumina ta can occur on the vulva.a condom won't .mata acumina ta are at risk for cancer of the c ervix a nd vulv a. Yearl y Pap s mears a re very importa nt for e arlydet ection.

and larynx. HPV can be transmit ted to other pa rts of the body. orophar ynx.protect sexual partners . such as the mouth. Rationa le: The left kidney usually is . 18. Answer : (A) The left kidney usually is slightly higher than the right one.

5cm (1") thick. in the posterio r aspect . 5 to 5.slightly higher than the right one. The kidneys are located retroper itoneall y. and 2. Anadre nal glan d lies at op each kidney.8 cm (2" to 2¼") wide. The av erage ki dney m easures approxi mately 11 cm (4-3/8") long.

They liebetwe en the 12th thoracic and 3rd lumbar vertebra e. 19. on either side of the vertebra l column. Answer : (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatini ne6.5 mg/dl.of the abdome n. Rationa le: .

the normal serumcr eatinine level ranges from 0. The test results in option Care abnorma lly elevated . reflectin g CRF and the kidneys' decrease d abilityto remov e nonpr otein ni .The normal BUN level ranges 8 to 23 mg/dl.7 to 1.5 mg/dl.

and phospho rous. A uric acid analysis of 3.trogen waste f rom the blood. magnesi um. CRF alsoincr eases serum levels of potassiu m. anddecr eases serum levels of calcium. CRF ca usesdec reased pH and increase d hydroge n ions — not vice versa.5 mg/dl .

sha pe.7 mg/dl. Answer : (D) Alt eration in the s ize. and organi zation of differ entiated cells Rationa le: Dysplasi a .fallswit hin the normal range of 2.7 to 7. 20. PSP excretio n of 75% alsofalls with the normal range of 60% to 75%.

An increase in the number of . T he pres ence of compl etelyun differen tiated tumor cells that don't resembl e cells of the tissues of their ori gin is called anaplasi a.refers t o an alt eration in the s ize. and organiz ation of differe ntiated cells. sha pe.

normal cells in anorma l arrang ement i n a tiss ue or a n organ is calle d hyperpla sia. Answer : . 21. Replace ment of one type of fully differen tiated cell by another in tissuesw here the second type normall y isn't found is called metapla sia.

22. Squamo us cell carcino ma. multiple myelom a.(D) Kaposi's sarcoma Rationa le: Kaposi's sarcoma is the most common cancer associat ed withAI DS. . and leukemi a mayocc ur in anyone and aren't associat ed specific ally with AIDS.

Answer : (C) To prevent cerebros pinal fluid (CSF) leakage Rational e: The clie nt receiv ing a su barachn oid bloc k require s special positioni ng to prevent CSF leakage and headach e and to ensure proper a nesthetic distributi on. Proper positioni ng doesn't help prevent confusio n.seizure .

Answer: (A) Ausculta te bowel sounds. or cardiac arrhythm ias. 23. Rational e: If abdomin al distentio n is accompa nied by nausea.s. the nursemu st first auscultat e bowel sounds. the nurse should suspect gastric or small intestine dilation and these findings . If bowel sounds are absent.

Palpatio n should be avoid ed postoper ativelyw ith abdomin al distentio n. If peristalsi s is absent. changing positions andinsert ing a rectal tube won't relieve the client's discomfo rt. Answer: (B) Lying on the left side with knees bent .mustbe reported to the physicia n. 24.

prone with the torso el evated.Rational e: For a colonosc opy. . 25. or bent over wit h handst ouching the floor wouldn't allow proper visualiza tion of the large intestine. Placing the client on the right side withlegs straight . the nurse initially should position the clienton the left side with knees bent.

Answer: (A) Blood supply to the stoma has been interrupt ed Rational e: An ileostom y stoma forms as the ileu m is brought through theabdo minal wall to the surface skin. creating an artificial opening for wasteeli mination . indi cating a dequatea . The sto ma shou ld appea r cherry red.

A dusky stoma suggests decrease d perfusio n.rterial perfusio n. A dusky stoma isn't a normal finding. whichma y result from interrupt ion of the stoma's blood supply and may lead totissue damage or necrosis. w hich dep ends on blood . Adjustin gthe ost omy bag wou ldn't affe ct stoma color.

26. Answer: (A) Applying knee splints Rational e: Applying knee splints prevents leg contractu res by holding the joints in a position of function. Elevatin g the foot of the bed can't preventc ontractu res because .supply to the area. An intestinal obstructi on also wouldn't change stomacol or.

Answer: . 27. Performi ng shoulder rangeofmotione xercises can prevent contractu res in the shoulder s. Hyperext ending a body part for an extended time is inapprop riatebeca use it can cause contract ures. but not in the legs.this action doesn't hold the joints in a position of functi on.

This client's PaO 100 mm Hg). White 2 pulmona value ry falls secretio within ns also thenorm arenorm al range al. The c (80 to lient's re . Rational e: A urine output of less than 40 ml/hour in a client with burnsind icates a fluid volume deficit.(B) Urine output of 20 ml/hour.

ctal tem perature isn't sign ificantly elevated andprob ably results from the fluid volume deficit. Rational e: The most importan t intervent ion to prevent pressure ulcers isfreque nt positi on chan ges. 28. Answer: (A) Turn him frequentl y. . whi ch reliev e pressu re on th e skin a ndunderl ying tiss ues.

D uring pa ssive ROM ex ercises.reducin g circulati on and oxygena tion of the tissues and resulting in celldeat h and ul cer form ation. capillari es become occluded . t he nurse moves each joint through its range of moveme nt. which improve s jointmob ility and .If pressu re isn't relieved.

A footboar d prevents plantar flexion and footdrop bymainta ining the foot in a dorsiflex ed position. 29. and downw ard stro .circulati on to the affected area but doesn't prevent pressure ulcers. eve n. Answer: (C) In l ong. Adequat e hydrati on is nec essary to maintai n health y skin and ensure tissue repair. outw ard.

Answer . a nd down ward str okes in t hedirecti on of hair growth. even. This applicati on pattern reduces the risk of follicl eirritatio n and skin inflamm ation. the nurse should begin at themidli ne and u se long.kes in t hedirecti on of hair growth Rational e: When applying a topical agent. 30. ou tward.

red ucing th e respo nse to c atechol amines andsym pathetic nerve stimulati on. helping toreduce the risk of another . They protect the myocard ium.: (A) Beta adrenergi c blockers Rational e: Betaadrenerg ic blockers work by blocking beta receptors inthe m yocardi um.

and decrease anxiety. Narcotic s reduce myocard ial oxygen demand. Calcium channel blockers reduce the workloa d of the heart bydecrea sing the heart rate.infractio n by decreasi ng myocard ial oxygend emand. Nitrates reduce myocard ialoxyge n consump tion bt decreasi ng left . promote vasodilat ion.

31.ventricul ar end diastolic pressure( preload) and systemic vascular resistanc e (afterloa d). Answer : (C) Raised 30 degrees Rational e: Jugular venous pressure is measure d with a centimet er ruler to obtain the vertical distance between the sternal angle and the .

point of highe st pulsatio n with the head of the bed inclined between 15 to 30degre es. not visible). In . Increase d pressure can‘t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point thatmark s the pressure level is above the jaw (therefor e.

highFow ler‘s position. are Answer: administ (D) ered to increase Inotropic the force agents of Rational theheart‘ e: s contra Inotropic ctions. Beta- . t agents hereby i ncreasin g ventri cular co ntractilit y andulti mately increasin g cardiac output. 32. the veins would be barely discernib le above the clavicle.

33. also decreasin g the workload of the heart. Answer : (B) .adrenergi c blockers and calciumc hannel blockers decrease the heart rate and ultimatel y decrease d theworkl oad of the heart. Diuretics are administ ered to decrease the overallva scular volume.

Less than 30% of calories form fat Rationa le : A client with low serum HDL and high serum LDL levels shouldg et less than 30% of daily calories from fat. The other modific ations areappr opriate for this client. 34. Answer : .

(C) The emerg ency de partme nt nurs e calls up the l atestele ctrocard iogram results to check the client‘s progress The em ergency depart ment n urse is no long er direc Rationa tlyinvol le: ved with the client‘s care and thus has no legal right to informa tionabo .

doing .ut his present conditio n. Anyone directly involve d in his care (such asthe telemetr y nurse and the on-call physicia n) has the right to informa tionabo ut his conditio n. Because the client requeste d that the nurse updatehi s wife on his conditio n.

Onc e the ai . Answer : (B) Rationa le: Check ET tube endotrac placeme heal nt tube should placeme be nt. confirm ed as soon as the clientarr ives in t he emer gency d epartme nt. doesn‘t breach confiden tiality.

V .oxyge nation and ventilati on should be confirm ed using an endtidal carbond ioxide monitor and pulse oximetr y. atropine . the nurse should make sureL. If the c lient ex perienc es sym ptomati cbradyc ardia.rways i s secure d. access is esta blished. Next.

Then the nurse should try to find the cause of the client‘s arrest by obtainin g an ABG adminis tered as ordered 0.5 to 1 mg every 3 to 5minute s to a total of 3 mg. ventricu . Amioda rone is indicate dfor ventricu lar tachyca rdia.

lar fibrillati on and atrial flutter – notsymp tomatic bradycar dia. Use the Answer followin g : formula (C) 95 to mm Hg calculat Rationa e le: MAPM AP = systolic +2 (diastoli c)3MAP =126 mm Hg + 2 (80 mm Hg)3M . 36.

testing for occultbl ood. complet e blood count.AP=286 mm HG3M AP=95 mm Hg 37. Rationa le: An electroc ardiogra m evaluate s the complai nts of chest . compreh ensive serum metaboli c panel. Answer : (C) Electroc ardiogra m.

pain. oxygen.lab oratory tests determi nes anemia.A basic . and creatine kinase and lactate dehydro genase levels are appropr iate for a cardiac primary problem . and the stool test for occult bloodde termine s blood in the stool. Cardiac monitor ing.

An elect roencep halogra mevaluat es brain .par tial thro mbopla stin tim e. Prothro mbin time.metabol ic panel and alkaline phospha tase andaspa rtate aminotr ansferas e levels assess liver function . fibrin ogen an d fibrin split pr oducts are measure d to veri fy bleed ing dysc rasias.

Altho ugh DIC and ITP cause pl atelet ag gregatio n andble eding. Answer : (D) Hep arinassociat ed thro mbosis and thro mbocyto penia(H ATT) Rational e: HATT may occur after CABG surgery due to heparin usedurin g surger y. neither is common in a client after .electrical activity. 38.

39. Methotre xate can caus . retaining more functioni ngplatele ts.revascul arization surgery. Answer : (B) Corticost eroids Rational e : Corticost eroid therapy can decrease antibody producti on andphag ocytosis of the antibody -coated platelets. Pancytop enia is a reduction in all blood cells.

e thrombo cytopeni a. Vitamin K is used totr eat an excessiv e anticoag ulate state from warfarin overload . 40. Answer : (D) Xenogen eic Rational e: An xenogen eic transplan t is between is between human andanot . and ASAdecr eases platelet aggregati on.

A sy ngeneic transpla nt is bet ween id entical t wins.her spec ies.all ogeneic transpla nt is bet ween tw o human s. 41. and a utologo us is atra nsplant from the same individua l. . Answer : (B) Rational e: Tissue t hrombo plastin i s release d when damage d tissuec omes in contact with clotting factors.

42.Calcium is released to assist theconve rsion of factors X to Xa. Conversi on of factors XII to XIIa and VIII toVIIIa are part of the intrinsic pathway.such as SLE and . Answer : (C) Essential thrombo cytopeni a Rational e: Essential thrombo cytopeni a is linked to immunol ogic disorders .

Mo derate to severe anemia is associat ed with SLE. not polycyth ermia.human immuno deficienc y vitus.Dr essler‘s syndrom e is pericardi tis that occurs after a myocardi al infarctio nand isn‘t . The disorder known asvon Willebra nd‘s disease is a type of hemophi lia and isn‘t linked to SLE.

linked to SLE. sympto ms include a single enlarged lymph node(us ually). a nd gener alizedpr uritis. m alaise. night s weats. Althoug h splenom egaly may be present in some clients. 43. nightsw eats are generall y more p . u nexplain ed fever. Answer : (B) Night sweat Rational e: In stage 1.

both . nor is hypother mia. 44. Mo reover. Pericard itis isn‘t associat ed with Hodgkin ‘s diseas e. Answer : (D) Breath sounds Rational e: Pneumon ia. s plenome galy and pericardi tis aren‘t sympto ms. Persisten t hypother mia is associ ated with Hodgkin ‘s but isn‘t an early sign of the disease.revalent.

bo welsoun ds. so frequent assessme nt of respirato ry rate andbreat h sounds is requir ed.viral and fungal. and heart sounds is importan t. is a common cause of deathin clients with neutrope nia. Answer : (B) Muscle spasm . 45. Alth ough ass essing bl ood pres sure. it won‘t help detect pneumon ia.

The other options. This should berecogn ized and treated promptly as progressi on of the tumor may result inparaple gia.Rational e: Back pain or parest hesia in the lower extremiti es may indicatei mpendin g spinal cord compres sion from a spinal tumor. which reflect parts of the nervous .

Answer : (A) Low platelet count Rational e: In DIC. 46.a ren‘t usually affected by MM.system. 47. platelets and clotting . Answer : (C)10 years Rational e: Epiderm iologic s tudies sh ow the aver age time from initialco ntact with HIV to the develop ment of AIDS is 10 years.

resulting inmicrot hrombi a nd exces sive blee ding. fibrin ogen lev elsdecre ase and the prot hrombin time in creases. Answer : (D) Hodgkin ‘s disease Rational e: Hodgkin ‘s disease . As clots for m. Fibrin d egenerat ionprodu cts increase as fibrinoly sis takes places.factors are consume d. 48.

they don‘t . Clients with sickle cell anemia manifest signs and sympto ms of chronica nemia w ith pallo r of the mucous membra ne. weightlo ss.typically causes fever night sweats. Influenz a doesn‘t last for months. and lymph mode enlarge ment. fatig ue. and decrease dtoleran ce for exercise.

L eukemi a doesn ‘t cause lymph nodeenl argement . Answer : (C) A Rhnegative Rational e: Human blood can sometim es contain an inherited D fever. night sweats. 49. weight loss or lymp h node enlarge ment. Persons with the D antigen have Rh- .

a nd sub s equent tr ansfusio ns with Rh- .positive blood type. I f Rhpositive blood is administ ered to an Rhnegative person. It‘s importa nt that a person with Rhnegative blood r eceives Rhnegative blood. the recipient develops antiRhagglu tinins. those lacking theantig en have Rhnegative blood.

anorexi a. Rational e: Persiste nt (more than 24 hours) v omiting. 50. Answer: (B) ―I will call my doctor if Stacy has persisten t vomitin g anddiarr hea‖. anddi arrhea are signs of toxicity and the .positive blood m aycause serious reactions with clumping and hemolysi s of red blood cells.

patient should stop the medicati on and notify the health care provider. Answer: (D) ―This is only tempora ry. . 51. Stacy will re- grow new hair in 36months. but may be different in texture‖. The other manifest ations are expected side effects of chemoth erapy.

Rational e: This is the appropri ate response . Answer: (B) Apply viscous Lidocain . it is still of the same color and texture. The nurse should help themoth er how to cope with her own feel ings regardin g the child‘s disease soas not to affect the child negativel y. 52. When the hair grows back.

the nurse can proceed with providin g the patientw ith oral r inses of saline so lution mixed w . When the patientis already comforta ble.e to oral ulcers as needed. Rational e: Stomatiti s can cause pain and this can be relieved by applyingt opical anestheti cs such as lidocaine before mouth care.

ith equal part of water or hydroge n peroxi de mixed w ater in 1: 3 concen trations t o promo te oralhy giene. Answer : (C) Immedia tely discontin ue the infusion Rational e: Edema or swelling at the IV site is a sign that the needle hasbeen dislodge d and the IV solution is leaking . 53. Every 24 hours.

54. The patient feels pain as the nerves are irritated by pressure andthe IV solution. The first action of the nurse would be to discontin ue theinfusi on right away to prevent further edema and other complica tion.into the tissues causing theedem a. Answer : (C) Chronic obstructi ve .

cyanotic nail beds. circumor al cyanosis. and attimes. theyhave large barrel chest and peripher al edema.bronchiti s Rational e: Clients with chronic obstructi ve bronchiti s appear bloated. Clients with ARDS are acutely short of breathan d freque ntly nee d intuba tion for mechani .

Clients with ast hma don ‘t exhibi t charact eristics of chroni c venti lation an d largea mount o f oxygen . 55. . Answer : (D) Emphyse ma Rational e: Because of the large amount of energy it takes to breathe. and clients with emphyse ma appear pink and cachectic .

clients with emphyse ma are usually cachecti c. They‘re pink and usuallyb reathe through pursed lips.‖ Clients with ARDSar e usually acutely short of breath. Clients with asthma don‘t have anyparti cular cha racteristi cs. and clien ts with chr onic obstructi ve bronchiti . hence the term ―puffer.

sare bloated and cyanotic in appearan ce. All other values are lower than expected. Answer :D 80 mm Hg Rational e: A client about to go into respirato ry arrest will have inefficie ntventila tion and will be retain ing carbon dioxide. 56. . The value expected wouldbe around 80 mm Hg.

57. The pH isless th an 7. academ ic. : (C) at 80 the Respirat mm Hg client ory and th has acidosis e metab respirat Rationa olicmea ory le: sure.35. Becaus HCO3Answer e Paco2 is is high normal. whic h elimin ates met abolic a . acidosis .

If the HCO3was below 22 mEq/L the clientw ould have metaboli c acidosis.nd respi ratoryal kalosis as possibil ities. Answer Rationa le: The client was : (C) reacting Respirat to the ory drug failure with . 58.

Rhe umatoi d arthrit is does n‘tmani fest . Althoug h the signs are also related to an asthma attack or a pulmon aryemb olism. which could lead to eventual ly respirat ory failure. c onsider the new drug fi rst.respirat ory signs of impe nding anaphyl axis.

Answer : (D) Elevated serum aminotr ansferas e Rationa le: Hepatic cell death causes release of liver enzyme s alaninea minotra nsferase (ALT). aspartat e amino transfer ase (AST) a nd lactated ehydrog enase (LDH) into the . 59.these signs.

circulati on. 60. Liver cirrhosi s is a chronic andirrev ersible disease of the liver ch aracteri zed by gene ralized inflamm ationand fibrosis of the liver tissues. Answer : (A) Impaire d clotting mechani sm Rationa le: Cirrhosi s of the liver results .

61. Answer : (B) Altered level of conscio usness Rationa le: Change s in behavio r and level of conscio usness are the firstsins .in decre ased Vitamin K absorpti onand formatio n of clotting factors resulting in impaire d clotting mechani sm.

This results in accumul ation of ammoni a andothe r toxic in the . Hepatic encepha lopathy is caused by liver fail ure and develop s when the liver is unable to convert protein metabol icprodu ct ammoni a to urea.of hepatic encepha lopathy.

blood that damages the cells. Answer : (C) ―I‘ll lower the dosage as ordered so the drug causes only 2 to4 stools a day‖. Rationa le: Lactulos e is given to a patients with hepatic encepha lopathy toreduce absorpti on of ammoni a in the . 62.

intestine s by binding with ammoni aand promoti ng more frequent bowel movem ents.Lact . it indicate s over dosage and the nurse must reduce the amount of medi cation given t o the p atient. If the patient experie ncediarr hea. The sto ol will be mas hy or s oft.

increase d WBC count.ulose is also very sweet and may cause crampin g and bloating. 63. d ecrease d blood pressur e. Rationa le: Severe lower b ack pai n indica tes an a neurys m ruptu . Answer : (B) Sev ere low er back pain.decrea sed RBC count.

Whenru ptured dary to pressure being applied within the abdomi nal cavity. the pain is constant because it can‘t s due to be alleviate the loss d until of blood the aneurys m is repaired. After the aneurys m ruptures. Blood pressure decrease . the vasculat .

For the samerea son. the RBC count is decrease d – not increase d. The WBC countinc reases as cell migrate to the site of injury. Answer: (D) Apply gloves and assess the groin site Rational e: . so blood pressure wouldn‘t increase. 64.ure is interrupt ed andbloo d volume is lost.

The goal in this situation is to stop thebleed ing.Observi ng stand ard prec autions i s the firs t priorit y whend ealing with any blood fluid. This establish es where the blood is coming from and determin eshow much blood has been lost. The nurse would . Assessm ent of the groin site is the secondpr iority.

vital signs assessm ent is importa nt. Answer: . The nurse should never move theclient . Moving can disturb the clot and causereb leeding. for help if it were warrante d after theasses sment of the situation. in case a clot has formed. After determin ing the extent of the bleeding.

An ech ocardio gram is a nonin vasive d iagnosis test.(D) Percutan eous translumi nal coronary angiopla sty (PTCA) Rational e: PTCA can alleviate the blockage and restore blood flow andoxyg enation. Cardiac catheteri zation is .Nit roglyceri n is an oral sublingu al medicati on.

Anaphyl actic shock results from an allergic reaction.adiagnos tic tool – not a treatment . 66. Distribut iveshock results from changes in the intravasc ular volume distributi . Answer: (B) Cardioge nic shock Rational e: Cardioge nic shock is shock related to ineffecti ve pumping of the heart.

on and isusually associate d with increase d cardiac output. This .tho ugh a severe MI can lead to shock. Answer: ( C) Kidneys‘ excretion of sodium and water Rational e: The kidneys respond to rise in blood pressure by excretin gsodium and excess water. MI isn‘t a shock state. 67.

response ultimatel y affects sysmolic bloodpre ssure by regulatin g blood volume. Sodium and water travel together across the membran e in the kidneys. 68. one can‘t travel without the other. Sodium or water retention wouldon ly further increase blood pressure. Answer : (D) It inhibits reabsorp tion of sodium .

and water in the loop of Henle. directlyr elaxing vascular smooth muscle and decr easing b lood pre . the reby cau sing a d ecrease i n bloodp ressure. Rational e: Furosem ide is a loop diuretic that inhibits sodium and water re absorpti on in th e loop H enle. Vasodila tors cause dilation of peripher al blood vessels.

69. elevated antinucle ar antibody (ANA) titer . Answer : (C) Pancytop enia.ssure.A drenergi c blocke rs decre ase sym pathetic cardioac celeratio n andde crease b lood pre ssure. A ngiotens inconverti ng enzy me inhi bitorsde crease blood pressure due to their action on angioten sin.

Rational e: Laborat ory find ings for clients with SL E usuall y showp ancytop enia. but the increase does not indicate SLE. Clients may hav e elevat ed BUN and cre atinine l evels fr omnephr itis. and dec reased s erum co mpleme ntlevels. ele vated A NA titer. Answer : (C) Narcotic s are avoided after a . 70.

Aspirin iscontrai ndicated .head injury because they mayhide a worsenin g condition . Rational e: Narcotic s may mask changes in the level of consciou snessthat indicate increased ICP and shouldn‘t acetamin ophen is strong enoughig nores the mother‘s question and therefor e isn‘t appropri ate.

such as trauma. there by mask ing cha nges in his leve l of cons ciousnes s. andfor children or young adults with viral illnesses due to the danger of Reye‘ssy condition s that may have bleeding. Answer . Stronger medicati ons may not nece ssarily lead to vomiting butwill sedate t he clien t. 71.

Oxygen ation ise . therefore . lowering Paco2 through hyperven tilationw ill lower ICP ca used by dilated cerebral vessels. low ering ca rbon dio xide (C O2) red ucesintra cranial pressure (ICP) Rational e: A norm al Paco 2 value is 35 t o 45 m m Hg C O2 has vasodilat ing propertie s.: (A) Appropr iate.

Alveolar hypoven tilationw ould be reflected in an increased Paco2. Answer : (B) A 33-yearold client with a recent diagnosi s of GuillainBarresyn drome Rational e: Guillain Barre sy ndrome is chara cterized by ascen dingpara lysis and potential .valuated through Pao2 and oxygen saturatio n. 72.

breathin g. There‘s no informati on to suggest the postmyo cardial infarctio nclient has an arrhyth mia or other complic ation. and thencircu lation.respirato ry failure. There‘s no evidence tosugges t . The order of client assessme ntshould follow client priorities . with disorder of airways.

73. Answer : (C) Decrease s inflamm ation Rational e: Then act ion of co lchicines is to de crease inflamm ation byr educing the migratio n of leukocyt es to synovial fluid. Colchici ne doesn‘tre place estrogen.hemorrh age or perforati on for the remainin g clients as a priority of care. .

It can afflict people of any age.decrease infection. Answer : (C) Osteoart hritis is the most common form of arthritis Rational e: Osteoart hritis is the most common form of arthritis and can beextre mely debilitati ng. although most areelderl y. 74. . or decrease bone deminera lization.

severe hypothyr oidism. Thyroid storm is lifethreateni ng but is caused . protrusio n of the eyeballs. Answer : (C) Myxede ma coma Rational e: Myxede ma coma . i s a lifethreateni ngcondit ion that may develop if thyroid replacem ent medicati on isn't taken.75.Ex ophthal mos. is seen with hyperthy roidism.

Tibial myxede severe hyperthy roidism. isassocia ted with hypothyr oidism but isn't lifethreateni ng. Answer: (B) An irregular apical pulse Rational e: Becaus e Cushi ng's syn drome c auses al dostero neoverpr oduction . peripher al mucinou s edema involvin g the lower leg. 76.

the nurse should immediat ely report signsand sympto ms of hypokale mia. to thephysi cian. Therefor e.. which increases urinary potassiu m loss. such as an irregular apical pulse. the disor der maylead to hypokale mia. Ed ema is a n expec ted find ing bec ause ald osteron eoverpr oductio n cause s sodiu .

Dry mu cousme mbranes and fre quent ur ination signal d ehydrati on. whi ch isn'ta ssociated with Cushing' s syndrom e. excessiv e . abo venormal s erumos molality level Rational e: In diabetes insipidus .m and f luid ret ention. Answer: (D) Belo wnormal u rine osm olality le vel. 77.

causing dehydrat ion that leads to anabove normal s erum os molality level. diabe tesinsipi dus doesn't cause abovenormal urine osmolali ty or below- . polyuria depletes the body of water. Fo r the sa me reaso ns. A t the sa me time.res ulting in a below normal urine os molality level.polyuria causes dilute urine.

B y recogn izing the signs of ." Rational e: Inadequa te fluid intake during hypergly cemic episodes oftenlea ds to H HNS. or eat more than usual.normalse rum osmolalit y levels. Answer: (A) "I can avoid getting sick by not becomin g dehydrat ed and bypaying attention to my need to urinate. 78. drink.

polydips ia. and p olyphagi a) and in creasing fluid int ake. Drinking a glass of nondiet soda would be appropri ate for hypo glycemia . A high- . A client whose diabetes is controlle d with oral antidiabe ticagents usually doesn't n eed to m onitor blood glucose levels.hypergl ycemia ( polyuria. the client m aypreven t HHNS.

carbohy drate diet would exacerba te the client's conditio n. Answer: (D) Hyperpar athyroidi sm Rational e: Hyperpa rathyroid ism is most common in older women and ischarac terized b y bone p ain and weaknes s from e xcess pa rathyroi dhormon e (PTH). particula rly if fluid intake is low. . 79.

Hypopar athyroidi sm ischaract erized by urinary frequenc y rather than polyuria 80.Clients also exhibit hypercal iuriacausing polyuria. Answer: (C) "I'll take two- . Whilecli ents with diabetes mellitus and diabetes insipidus also have polyuria. they don't have bone pain and increase d sleeping.

therefore ." Rational e: Hydroco rtisone. twothirds of the dose of hydrocor tisone shouldbe .thirds of the dose when I wake up and onethirdin the late afternoo n. should be admi nistered accordin g to a schedule that closely reflects the body's own secretion of this hormone . a glucoc orticoid.

Answer: (C) High corticotr opin and high cortisol levels Rational e: A cortic otropinsecretin g pituita ry tumor would c ause hig hcorticot ropin and high cortisol levels. 81. This dosagesc hedule reduces adverse effects.taken in the morning and onethird in the late afternoo n. A high corticotr opin level .

Low corticotr opin and high cort isol levelswo uld be seen if there was a primary defect in the adrenal glands. Answer: (D) Performi ng capillary glucose .with a lowcortis ol level and a low corticotr opin level with a low cortisol level would beassoci ated with hyp ocortisol ism. 82.

isn't at .testing every 4 hours Rational e: The nurse should perform capillary glucose testing every 4hours because excess cortisol may cause insulin resistanc e. placing theclient at risk f or hyper glycemi a. Urine ketone t esting is n't indic atedbeca use the client does secrete insulin and. therefor e.

83. Urine specific gravity isn't indi cated be cause alt hough fl uidbalan ce can be compro mised. and its peak to . Answer: (C) onset to be at 2:30 p.risk for ketos is.Tem perature regulatio n may be affected by excess cortisol and isn't anaccura te indicator of infection. it usually isn't dangero usly imbalan ced.m.

Answer: (A) No increase .. which is a shortacting insulin.m. to 2:30 p.and the peak from 4 p. the expected onset would be from 2:15 p.m.m. to 6 p. has an onset of 15 to 30 minutes and a peak of 2 to 4 at 4 p.m. Because the nurse gave theinsuli n at 2 p.m. Rational e: Regular insulin. 84.

in the thyroidstimulati ng hormone (TSH) levelafte r 30 minutes during the TSH stimulati on test Rational e: In the TSH test. Belownormal levels of . failure of the TSH level to rise after 30minut es confir ms hype rthyroidi sm. A de creased TSH lev el indica tes apitui tary deficienc y of this hormone .

signal hypothyr oidism. A belownormal T4level also occurs in malnutri tion and liver disease and may result fromadm inistratio n of phenytoi n and certain other drugs. . Answer: (B) "Rotate injection sites within the same anatomic region. asdetecte d by radioim munoass ay.T3 and T4. 85.

als o. insulin absorpti on differs from one .notamon g different regions. Rotating sites among different regions may cause excessiv e day-today variation s in the blood glucose level." Rational e: The nurse should instruct the client to rotate injection siteswith in the same anatomic region.

Insulin should tissue lacking large blood be vessels. Injectin g insulin into areas of hypertro phymay delay a bsorptio n.region to the next. injected nerves. only or scar into hea tissue or lthy other deviatio ns. The clie nt shoul dn't inject insulin into are .

as of lip odystro phy (such as hypertro phy or atrophy) . Exe rcise sp eedsdru g absorpti e client should r otate inj ection s ites syst ematica lly. to prevent lipodyst rophy. so t he client s houldn't inject i nsulin i nto sites ab ovemus cles that will be exercise d heavily. .

hypergl ycemic state caused by the relat ive .86. which occurs seconda ry to th e hyper osmolar . Answer : (D) Belownormal serum potassiu m level Rationa le: A client with HHNS has an overall body deficit of potassiu mresulti ng from diuresi s.

not serum alkalosi s. 87. may occur in HHNS. Metabol ic acidosis . Answer : (D) Maintai ning room temperat ure in the low- .insulin deficien cy. An elevated serum a cetone l evel an d serum ketone bodies are char acteristi c of dia betic ketoacid osis.

T o reduc e heat i ntolera nce and diaphor esis. excessiv e thirstan d appet ite.normal range Rationa le: Graves ' disea se cau ses sig ns and sympt oms of hyperm etabolis m. diaphor esis. such as heat intolera nce. the nurse should keep the client's . and weight loss.

not restrict. intake of oral fluids. To provide . Placing extra blankets on thebed of a client with heat intolera nce would cause discomf ort. To replace fluids lost via diaphor esis. the nurse shoulde ncourag tempera ture in thelownormal range.

needed energy and calories. Answer : (A) Fracture of the distal radius Rationa le: Colles' fracture is a fracture of the distal radius. 88. the nurse should encoura ge the client to eathighcarbohy drate foods. such as froma f all on a n outstr .

It 's most commo n in wo men. or carpalsc aphoid.etched hand. humeru s. bones l ose calc ium and . C olles'fra cture doesn't refer to a fracture of the olecran on. 89. Answer : (B) Calcium and phospho rous Rationa le: In osteo porosis.

brittle. Answer : (A) Adult respirato ry distress syndrom e (ARDS) Rationa le: .phosph ate salts . 90. Sodium and potassiu m aren't involved in the develop ment of osteopor osis.becomi ng porous. and abnorm ally vulnera ble to fracture.

Answer : (D) Fat embolis m Rationa le: Long bone fra ctures a re . 91.Severe hypoxia after smoke inhalati on is typicall y related toARD S. The other conditio ns listed aren‘t typicall y associat ed with smokein halation and severe hypoxia.

92. whichc ause sh ortness of breat h and h without a previo us histor y. It‘s un likely t he clien t has produce progressi ve hypoxia. Answer: (D) Spontane ous . He co ulddevel op develop atelectasi ed asth s but it ma or br typically onchitis doesn‘t ypoxia.correlat ed with fat emb oli.

pneumot horax Rational e: A spontane ous pneumot horax occurs when the client‘s lungcoll apses. An asthma attack would show . causing an acute decrease d in the amount of function al lungused in oxygenat ion. The sudden collapse was the cause of his chest painand shortnes s of breath.

p neumoni a. it‘s unlikely he hasbron chitis. an d bronc hitis wo uld have rhonchi . or TB.wheezin g breathso unds. Answer: (C) Pneumot horax Rational e: From the trauma the client experien ced. Pneum onia wo uld have bronchial breath sounds over the area of consolid ation. 93. rhonchi with bro .

Air can‘t . Answer : (C) Serous fluids fills the space and consolid ates the region Rational e: Serous f luid fills the spa ce and e ventuall y consol idates. bronchia l breaths ounds with TB would be heard.nchitis. eventing extensiv e mediasti nal shift of the heart and remainin g lung.

be left in the space. Answer : (A) Alveolar damage in the infracted area Rational e: The infracted . Th e tissue from the other lu ng can‘t cross th e media stinum. There‘s no gel that can be placed in the pleurals pace.a lthough a temporar y mediasti nal shift exits until the space is filled. 95.

96. There‘s a loss of lung parenchy maand subseque nt scar tissue formatio n.area produces alveolar damage that can lead tothe producti on of bloody sputum. Clotfor mation usually occurs in the legs. Answer : (D) Respirat ory alkalosis Rational e: . sometim es in massive amounts .

A client with massive pulmona ry embolis m will have a largeregi on and blow off large amount of carbon dioxide. Answer : (A) Air leak Rational e: . which crosses theunaff ected alveolarcapillary membra ne more readily than does oxygena nd results in respirato ry alkalosis. 97.

Bubblin g doesn‘t normally occur with either ad equate or inadequa te suction or any preexisti ng bubbling in the water se .Bubbling in the water seal chamber of a chest drainage systemst ems from an air leak. In pneumot horax an air leak can occur as air ispulled from the pleural space.

al chamber. Answer : (B) 21 Rational e: 3000 x 10 divided by 24 x 60. Answer: (B) 2. Answer: (D) ―I should put on the stocking s before getting out of bed inthe morning. 98.05 mg/ 1 ml = .4 ml Rational e: .05x = . x = 2. Rational e: Promote venous . 99. .12.4 ml.12mg/ x ml. 100.

Answer : (D) Focusing Rational e : The nurse is using focusing by suggestin g that the clientdis cuss a specific issue. The nurse didn‘t restate the . TEST VAnswe rs and Rati onale – Care of Clients with Ph ysiologic andPsyc hosocial Alterati ons 1.return by applying external pressure on veins.

Answer : (D) Remove all other clients from the dayroom . 2. Rational e : The nurse‘s first priority is to consider the safety of the clientsin the therapeut ic setting.question. The other actions are appropri ate . or ask further question (explorin g). makeobs ervation.

response safter ensuring the safety of other clients. Answer : (A) The client is disruptiv e. Rational e : Group activity provides too much stimulati on. Answer : (C) Agree to . 3. 4. which the clientwill not be able to handle (harmful to self) and as a result will be disruptiv eto others.

the nurse can providee motional support and further assess and validate the family‘s needs. 5. Answer : (A) Perceptu al disorders .talk with the mother and the father together. Rational e : By agreeing to talk with both parents. Rational e : Frighteni ng visual hallucina tions are .

Answer . 7. 6.especiall y common inclients experien cing alcohol withdraw al. Rational e : The client needs a specific response. Answer : (D) Suggest that it takes awhile before seeing the results. that it takes 2 to 3 weeks(a delayed effect) until the therapeut ic blood level is reached.

Answer : (C) Skeletal muscle paralysis. Rational e : Anectine is a depolariz ing muscle relaxant causing .: (C) Superego Rational e : This behavior shows a weak sense of moral consciou sness.Ac cording to Freudian theory. personali ty disorders stem from a weaksup erego. 8.

carbohyd rates. Rational e : This client increased protein for tissue building and increased . Itis used to reduce the intensity of muscle contracti ons during theconvu lsive stage. thereby reducing the risk of bone fractures or disloc ation.paralysis. and protein. Answer : (D) Increase calories. 9.

Answer : (A) By designati ng times during which the client . 11. Answer : (C) Acting overly solicitou s toward the child. Rational e : This behavior is an example of reaction formatio n. a copingm echanism .calories to replace what is burned up (usually via carbohyd rates) 10.

She shouldn't call . not rapidly. The nursesho uld urge the client to reduce the frequenc y of the compulsi ve behavior gradually .can focus on thebehav ior. Rational e : The nurse should d esignate times during which the client canfocus on the compulsi ve behavior or obsessiv e thoughts.

The nurse should encourag e the client to verbalize anxieties to helpdistr act attention from the compulsi ve behavior. 12. Answer : (D) Explorin g the meaning of the traumatic .attention to or try to prevent thebehav ior. Trying to prevent the behavior may cause pain and terror in theclient.

event with the client.Ot herwise. symptom s may worsen and the client may become depresse dor engage in selfdestructi ve behavior such as substanc . Rational e : The client with PTSD needs encourag ement to examine andunder stand the meaning of the traumatic event and conseque nt losses.

The physicia n may prescribe antianxie ty agents or antidepre . may help decrease the client's anxiety and inducesle ep. Theclient must explore the meaning of the event and won't heal without matter how much time passes. such asrelaxat ion therapy. Behavior al techniqu es.e abuse.

Answer : (C) "Your problem is real but there is no physical basis for it. 13. Aspecial diet isn't indicated unless the client also has an eating disorder or a nutrition al problem.We'll work on what is going on in your life to find out . sleep medicati on is rarely appropri ate.ssantscau tiously to avoid depende nce.

" Rational e : The nurse must be honest with the client by telling her that theparaly sis has no physiolo gic cause while also conveyin g empathy andackn owledgin g that her symptom s are real. which will help her understa nd the .why it's happene d. The client will benefit frompsyc hiatric treatment .

her symp toms will disappea r.underlyi ng causeof her symptom s. After the psycholo gical conflict is resolved. Tellingh . knowing that thecause is psycholo gical wouldn't necessari ly make her feel better. Saying that it must be awful not to be able tomove her legs wouldn't answer the client's question.

Answer : (C) fluvoxa mine (Luvox) and clomipra mine (Anafran il) Rational e : The antidepre ssants flu . that she has develope d paralysis to avoid leaving her parents or thather personali ty caused her disorder wouldn't help her understa nd andresol ve the underlyi ng conflict.

Librium and Valium may be helpfulin treating anxiety related to OCD but aren't drugs of choice to treat the illness. 15.voxamin e and clom ipramine havebeen effective in the treatment of OCD. The other medicati ons mentione d aren't effective in the treatment of OCD. Answer : (A) A warning about the drugs delayed .

The client must be instructe d tocontinu e taking the drug as directed.NMS hasn't . Rational e : The client should b e informed that the drug's therapeut ic effectmi ght not be reached for 14 to 30 days.therapeut ic effect. whichis from 14 to 30 days. Blood level checks aren't necessar y.

but tachycar dia is frequentl yreporte d. Physicals igns and symptom s of phobias include . Rational e : Phobias cause severe an xiety (such as a panic attack) th at isout of proportio n to the threat of the feared object or situation.been reported with this drug. 16. Answer : (B) Severe anxiety and fear.

Answer : (A) Antidepr essants Rational e . an inability toconcen trate. 17. Insomnia .profuse sweating. and elevated blood pressure. and weight loss are common in depressio n. Withdra wal andfailur e to distingui sh reality from fantasy occur in schizoph renia. poor motor co ntrol. tachycar dia.

: Tricycli c and mon oamine oxidase ( MAO) inhibitor antidepre ssants have been found to be effective in treating clients withpani c attacks. Anticholi nergic agents.relieve physical symptom . which are smoothmuscle relaxants . Why these drugs help control panic attacks isn't clearlyun derstood.

s of anxiety but don't relieve the anxiety itself. 18. Mood stabilizer s aren't indicated becausep anic attacks are rarely associate d with mood changes. Answer : (B) 3 to 5 days Rational e : Monoa mine .Ant ipsychoti c drugs are inapprop riate because clients who experien cepanic attacks aren't psychoti c.

Answer : (B) Providin g emotiona l support and individua l . havean onset of action of approxi mately 3 to 5 days. such as tranylcyp romine. A full clinical response may be delayed for 3 to 4 weeks. The therapeut ic effects may continue for 1 to 2 weeks after discontin uation. 19.oxidase i nhibitors.

nursing care typically focuses on providin gemotion al support and individua l counseli ng. Rational e : Clients in the first stage of Alzhei mer's disease are aware th atsometh ing is happenin g to them and may become overwhel med andfright ened. Therefor e. The other .counseli ng.

options areappro priate during the second stage of Alzheim er's disease. offering nourishin . During this stage. when theclient needs continuo us monitori ng to prevent minor illnesses fromprog ressing into major problems and when maintaini ng adequate nutrition may become a challeng e.

and impaired memory Rational e : Signs of antian xiety agent overdose include emotiona l lability.e uphoria. and impaired memory. Phencycl idine overdose can causeco . Answer : (C) Emotion al lability. euphoria.g finger fo ods helps clients to feed themselv es and maintain adequate nutrition 20.

hyperacti vity. and increased bloodpre ssure. Hallucin ogenover dose can produce suspiciou sness. and grandios e ideation.mbativen ess. and confusio n. 21. Answer : (D) A low tolerance for frustratio n Rational e . sweating. dilated pupils. Ampheta mine overdose canresult in agitation.

and quit work without other plans for employm ent. They don'tfeel guilt about their .: Clients with an antiso cial personali ty disorder exhibit a lowtole rance for frustratio n. emotiona l immaturi ty. They commonl y have a history of unemplo yment. miss workrepe atedly. and a lack of impulsec ontrol.

behavior and commonl y perceive themselv es asvictims . Answer . They also display a lack of responsi bility for the outcome of their acti ons. closerela tionships . clients with antisocia lpersonal ity disorder commonl y have difficulty developi ng stable. 22. Because of a lack of trust in others.

Barbitura tes. heroin. and morphin e. ampheta mines. .: (C) Methado ne Rational e : Methado ne is used to detoxify opiate users because it bindswit h opioid receptors at many sites in the central nervous system butdoesn ‘t have the same deterious effects as other opiates. such ascocain e.

23. Delusion s are falsebeli efs.andbenz odiazepi nes are highly addictive and would require detoxific ationtreat ment. rather . Answer : (B) Hallucin ations Rational e : Hallucin ations are visual. auditory. tactile. gustatory . or olfact ory perceptio ns that have no basis in reality.

24. Rational e : Establish ing a consisten t eating plan and . Looseass ociations are rapid shifts among unrelated ideas. Neologis ms arebizarr e words that have meaning only to the client. Answer : (C) Set up a strict eating plan for the client.than perceptio ns. that the client accepts as real.

monitori ng theclient‘ s weight are very importan t in this disorder. . Exercise must be limited and supervise d. The family and friendssh ould be included in the client‘s care. The client should be monitore dduring mealsnot given privacy. 25. Answer : (A) Highly importan t or famous.

A delusion of persecuti on is a false belief that one isbeing persecute d.Rational e :A delusion of grandeur is a false belief that one is highlyim portant or famous. A delusion of reference is a false belief that one isconnect ed to events unrelated to oneself or a belief that one .

Rational e : The nurse should listen to the client‘s requests. expressw illingnes s to seriously consider the responsi blefor the evil in the world 26. The . Answer : (D) Listening attentivel y with a neutral attitude and avoiding power struggles . and respond later.

High calorie finger foods should be offered to supplem . The nurse shouldn‘t try to restrain the clientwh en he feels the need to move around as long as his activity isn‘thar mful.nursesho uld encourag e the client to take short daytime naps because heexpen ds so much energy.

The nurse should set limits in a calm. Answer : (D) Denial Rational e : Denial is . clear.ent theclient‘ s diet. and selfconfident toneof voice. 27. if he can‘t remain seated long enough to eat a complete meal.The nurse shouldn‘t be forced to stay seated at the table to finid=sh ameal.

character ized by apathy. desires.L ogical thinking is the ability to think .Withdr awal is a common response to stress. or external facts that are consciou sly intolerab le. impulses.unconsci ous defense mechanis m in which emotiona lconflict and anxiety is avoided by refusing to acknowl edge feelings.

28.rationall y and make responsi bledecisi ons. Repressi on is suppressi ng past events from the consciou snessbec ause of guilty associati on. which would lead the client admittin g the problem and seekingh elp. Answer : (B) Paranoid thoughts Rational e : Clients with schizoty pal personali .

reg ardless of the situation. Their behavior is emotiona lly cold with a flattened affect.ty disorder experien ceexcessi ve social anxiety that can lead to paranoid thoughts. These clients demonstr ate a reduced . although these clients may experien ce agitation with anxiety. Aggressi vebehavi or is uncomm on.

capacityf or close or depende nt relations hips. 29. Answer : (C) Identify anxietycausing situation s Rational e : Bulimic behavior is generally a maladapt ive coping response tostress and underlyi ng issues. The client must identify anxietycausingsi tuations that .

30. Answer : (A) Tension and irritabilit y Rational e : An ampheta mine is a nervous system stimulant that is subjectto abuse because of its ability to produce wakefuln ess and euphoria. Anoverd ose .stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

but I believe you can .increases tension and irritabilit y. Answer : (B) ―No. I do not hear your voices. 31. which increase theheart rate and blood flow. Diarrhea is a common adverse effect so optionD in is incorrect. Options B and C are incorrect because ampheta mines stimulate norepine phrine.

Answer : (C) Confusio n for a time after treatment Rational e : The electrical energy passing through the cerebral cortexdu ring ECT results in .ac cepts the client‘s perceptio ns even though they are hallucina tory. Rational e : The nurse.hear the m‖. 32. demonstr ating knowled ge and understa nding.

Answer : (D) Acceptan ce stage Rational e : Commun ication and intervent ion during this stage are mainlyno nverbal. Answer : (D) A higher level of anxiety continuin . 33. 34. as when the client gestures to hold the nurse‘s hand.a temporar y state of confusio n after treatment .

.g for more than 3 months. 36. Answer : (B) Staying in the sun Rational e : Haldol causes photosen sitivity. Severe sunburn can occur onexpos ure to the sun. Rational e : This is not an expected outcome of a crisis because bydefinit ion a crisis would be resolved in 6 weeks. 35.

these clients usually have verynarr ow. Answer : (C) Diverse interest Rational e : Before onset of depressi on. 37. Answer . limited interest.Answer : (D) Moderat e-level anxiety Rational e :A moderate ly anxious person can ignore periphera l events andfocus es on central concerns. 38.

39. Answer : (D) Disturba nce in recalling recent events related to cerebral hypoxia.: (A) As their depressio n begins to improve Rational e : At this point the client may have enough energy to plan andexec ute an attempt. Rational e : Cell damage seems to interfere with registeri .

which af fects the abilit y to regi ster and recall recent events. Rational e : Blood levels must be .ng input stimuli. Answer : (D) Encoura ging the client to have blood levels checked asordere d. 40. v ascular d ementia is related to multiple vascular lesions of the cerebral cortex andsubc ortical structure.

Answer : (B) Fine hand tremors or slurred speech Rational e : These are common side effects of lithium carbonat e. .checked monthly or bimonthl y when theclient is on mainten ance therapy because there is only a small rangebet ween therapeut ic and toxic levels 1.

Answer : (A) Client‘s perceptio n of the presentin g problem.42. Answer : (D) Presence Rational e : The constant presence of a nurse provides emotion al supportb ecause the client knows that someone is attentive and available in caseof an emergen cy. Rational e . 43.

because it is the client‘s concept of the problem that serves as thestartin g point of the relations hip. and yogurt‘‖ Rational e : These hightyramine foods. aged cheese. Answer : (B) Chocolat e milk.: The nurse can be most therapeu tic by starting where the clientis. 44. when ingested .

in the presence of an MAO inhibitor. Answer : (D) Males are more likely to use lethal methods than are females Rational e : This finding is supporte d by research. Answer : (B) 4 to 6 weeks Rational e : Crisis is selflimiting and lasts from 4 to 6 weeks. females . 46. 45. cause a severe hyperten sive response.

Take time out in your roo m for 10 minutes. " Rational e : The nurse should set limit s on client . Answer : (C) "Your cursing is interrupti ng the activity.account for 90%of suicide attempts but males ar e three times mo re successf ul because of metho ds used. 47.

as in option A.behavior to ensur e acomfort able environ ment for all client s. Option B is incorrect because it implies that theclient' s actions reflect feelings toward the staff instead of the . The nurse should accept hostile o r quarrel some cli ent outb ursts wit hin limit s withou t becomi ng perso nallyoffe nded.

an antimani a drug. such as option D. is used to treat clientswi th cyclical schizoaff ective disorder. Judgmen tal remarks. 48. Answer : (C) lithium carbonat e (Lithane) Rational e : Lithiu m carbonat e.client's ownmise ry. may decrease the client'sse lfesteem. a psychoti .

c disorder once classifie dunder schizoph renia that causes affective sympto ms. includin g maniclik eactivity . Lithiu m helps control t he affect ive com ponent o f this disorder. Phenelzi ne is a monoam ine oxidase inhibitor prescribe d for clients whodon' t respon d to oth er antid epressa nt drugs such as .

ge nerally i s contrai ndicated inpsych otic clie nts.Ch lordiaze poxide. is also used to treat clients with agoraph obia and that undergoi ngcocain e detoxific ation. Imip ramine. an antia nxiety a gent. 49.imipra mine. primaril y consid ered an antidepr essantag ent. Answer : (B) Report a sore throat or .

Becau se of the risk of agranulo cytosis.fever to the physicia n immedia tely. a potential ly lifethreateni ng complic ation of clozapin e. Rationa le :A sore thro at and fever are indicatio ns of an infect ion causedb y agranulo cytosis. white blood .

Hypoten sion may occur in clients takingth is medicati on.000/μl .the medicati on must be stopped. If the WBC count drops below 3. not monthly . Warn the client to stand up slowly to avoid dizzines s .cell (WBC) counts areneces sary weekly.

If the medicati on must be stopped. even whensy mptoms have been controll ed. The medicati on should be continue d.fromort hostatic hypoten sion. . itshould be slowly tapered over 1 to 2 weeks and only under thesuper vision of a physicia n.

est Rationa neurolep : (C) le ticmalig Neurole : The nant ptic client's syndrom maligna signs an e.50. syndrom ms sugg Answer e. a lifent d threateni sympto ng reaction to neurolep tic medicati onthat requires immedia te .

Dystoni a is characte rized by cramps and rigidity of the tongue. . and back muscles. mouth. Tardive dyskines ia causes involunt arymove ments of the tongue. facial muscles. and arm and legmusc les.f ace. Akathisi a causes restlessn ess. neck.treatmen t.

51. and jitte riness. Answer client to sit up for 1 minute before getting : (B) out Advisin of bed.anxiety. the nurse should advise the . g the Rationa le : To minimiz e the effec ts of amitri ptyline- induced orthostat ichypote nsion.

another tricyclic antidepr . the dosage may bereduc ed or the physicia n may prescrib e nortripty line. In these cases. Orthosta tic hypoten sion common ly occurs withtric yclic antidepr essant therapy.client to sit up for 1 minuteb efore getting out of bed.

Orthosta tic hypoten sion disappea rs only when the drug isdiscon tinued.essant. gs of depre ssion lastingat least 2 years. accomp anied by at least two of . 52. Answer Rationa le : Dysthy mic disorder : (D) is marke Dysthy d mic by feelin disorder.

difficult y making decision s. These sympto ms may be relativel y continuo us or separ ated by interven . low selfesteem. appetite disturba nce. andhope lessness. poor concentr ation.the followin g sympto ms:sleep disturba nce. low energy or fatigue.

ing periods of normal mood that last a few days to afew weeks. Atypical affective disorder is characte . Cycloth ymic disorder is a chronic mood disturba nce of at least2 years' duration marked by numero us periods of depressi on andhypo mania.

persiste nt sadness or loss of intere st or pleasure in almost all activitie s.rized by manic signs andsym ptoms. Major depressi on is a recurrin g. Answer : (C) 30 g mixed in 250 . with signs and sympto msrecur ring for at least 2 weeks. 53.

Doses less than this will be ineffecti . mixed in 250 ml of of water of activa ted charcoal Rationa is 5 to 10 le timesthe : The estimate usual d weight adult dosage of the drug or chemica l ingested . or a minimu m doseof 30 g.

althou gh toxicity doesn't occur with activate d charcoal . even at themaxi mum dose. 54. John's wort has been . Answer : (C) St. John's wort Rationa le : St.doses greater than this can increase the risk of adverse reaction

similar to prescript ion antidepr essants. Echinac ea has immune stimulati ngprope rties. Ginkgo biloba isprescri bed to enhance mental acuity. Ephedra is a naturall y occurrin g stimulan t that is similar .found to have ser otoninelevatin gpropert ies.

55.toephedr ine. Clients taking lithium . increasi ng the risk of toxicity. such as from sweatin g or diuresis. lithium will be reabsorb ed bythe kidneys. If Rationa sodium l le evels arereduc ed. Answer : Lithiu m is chemica lly similar : (B) to sodiu Sodium m.

The other electroly tes are importa nt for normal body function sbut sodium is most importa nt to the absorpti on of lithium. 56. Answer : (D) It's characte .shouldn' trestrict their intake of sodium and should drink adequat e amounts of fluideac h day.

rized by an acute onset and lasts hours to anumber of days Rationa le : Deliriu m has an acute onset and typi cally can last fromsev eral hours to several days. 57. Answer commun ication. Rationa le : Initiall y. : (B) memory Impaire impairm d ent may .

s ubtle personal ity changes may also be present. other thanocc asional irritable outburst s and lack of spontan eity. During the early stage of this the only cog nitive deficitin a client with Alzheim er's disease. Howeve r. the client is usuallyc ooperati ve and exhibits .

. actions. such as inappro priate convers ation. Signs of advan cement to the middle stage of Alzheim er's disease includee xacerbat ed cognitiv e impairm ent with obvious personal ity changes andimpa ired commun ication. andresp onses.socially appropri ate behavior .

Rationa le : Sedatio n is a comm on early . 58. which shouldb ecome less botherso me over time. the client can't perform selfcareacti vities and may become mute.During the late stage. Answer : (D) This medicati on may initially cause tirednes s.

and usually decrease s as toleranc e develop s. the dosage .Antide pressant s aren't habit forming and don't cause physical or psych ological depende nce. Howeve r. after a long course of highdosether apy.adverse effect of imipram ine. atricycli c antidepr essant.

are necessar . and tachycar dia. yogurt. includem yocardial infarctio n. and chicken livers. Serious adverse effects.such as avoiding aged cheeses.should be decrease d graduall y to avoid mild withdraw al symptom s. Dietary restrictio ns. heart failure. although rare.

Rational e : An anorexic client who requ ires hospitali zation is in poor p hysical condition from starvatio n and may die .yfor a client taking a monoami ne oxidase inhibitor. 59. and acidbasebala nce. not a tricyclica ntidepres sant. serum electrolyt e levels. Answer : (C) Monitor vital signs.

serumele ctrolyte level.hypot a result of arrhythm ias. Option A may worsena nxiety. infection. malnutrit ion. Therefor e. monitori ng the client's vital signs. Option B is incorrect . and acid base balance is crucial. or cardiac abnormal ities secondar y toelectrol yte imbalanc es.

Option D wouldre ward the client with attention for not eating and reinforce the controlis sues that are central to the underlyi ng psycholo gical problem. theclient may record food and fluid intake .because a weight obtained after breakfast ismore accurate than one obtained after the evening meal. also.

Sympto ms of cocaine withdraw al include depressio n. . There is no real withdraw alfrom cannibis. Alcohol withdraw al would show elevated vital signs. and agitation.inaccurat ely.anxiety . 60. Answer : (D) Opioid withdraw al Rational e : The symptom s listed are speci fic to opioid withdraw al.

61. In reaction . the client blames someone or somethin g other tha n the source. or behavior that is appropri ate at ayounger age. isdisplay ing regressiv e behavior. Answer : (A) Regressi on Rational e : An adult who throws te mper tantrums. In projectio n. such as this one.

and face. 62. In intellectu alization.formatio n. the client overuses rational explanati ons or abstra ct thinking to decrease the significa nce of a feeling or event. the client acts in oppositio n to hisfeelin gs. . Answer : (A) Abnorma l moveme nts and involunta ry moveme nts of themouth . tongue.

and face.Rational e : Tardive dyskinesi a is a severe reaction associate d with longterm use of antipsyc hotic medicati on. The clinical manifest ations includea bnormal moveme nts (dyskine sia) and involunta ry moveme nts of themouth . tongue (fly catcher tongue). Answer : (C) Blurred vision . 63.

5 and 2 mEq/L the clientexp eriencing vomiting . ataxia. muscle weaknes s.Rational e : At lithium levels of 2 to 2. diarrhea.slurred speech. muscle twitching . and persisten tnausea and vomiting . and confusio . With levels between 1. dizziness . severe hypotens ion.5 mEq/L the client will experien cedblurre d vision.

5 to 3 mEq/L or higher. 64. and death. cardiacd ysrythmi as. periphera l vascular collapse. Answer : (C) No acts of aggressio n have been observed within 1 hour afte r the release of two of the extremit y . At lithium levels of 2.n. urinary and fecal incontine nce occurs. as well as seizures.

B. if the clientexh ibits no signs of aggressio n after partial release of restraints .restraints . Options A. 65. Answer: (A) increased attention span and concentr ation . Rational e : The best indicator that the behavior is controlle d. and D do not ensure that the client has controlle d the behavior.

insomnia . Sideeffec ts of Ritalin include anorexia. D. diarrhea and irritabilit y. Answer: (C) Moderat e Rational e : The child with moderate mental . 66. B.Rational e : The medicati on has a paradoxi c effect that decrease hyperacti vity and impulsivi ty among children with ADHD. C.

of 20-35.retardati on has an I.Q.Q. of below 20. Answer: (D) Rearrang e the environ ment to activate the child Rational e : The child with autistic disorder does not .Q. Mild mentalret ardation 50-70 and Severe mental retardati on has an I. 67. of 35-50 Profound Mental retardati on has an I.

C. Ensure safety from selfdestructi ve behavior s likehead banging and hair pulling. Acceptan ce enhances atrusting relations hip. 68. Answer: . B. A.want change. Angry outburst canbe rechanneli ng through safe activities . Maintain ing a consisten t environ ment is therapeut ic.

a CNSstim ulant.(B) cocaine Rational e : The manifest ations indicate intoxicati on with cocaine. C. Intoxicat ion with hallucino gen like LSD is manifest ed bygrandi . A. attention and the presence of papillary constricti on. Intoxicat ion with heroine is manifest ed by euphoria thenimpa irment in judgment .

a cannabin oid is manifest ed by sensation of slowe d time. synesthe sia and increase in vital signs D. impaired judgment and hallucina tions. 69. hallucina tions. Answer : (B) insidious onset Rational e .osity. social withdraw al. conjuncti val redness.Intoxic ation with Marijuan a.

A. 70.C and D are allcharac teristics of delirium. A. Agoraph obia is fear of open . Itcauses pronounc ed memory and cognitive disturban ces.: Dementi a has a gradual onset and progressi ve deteriora tion. Answer: (C) Claustro phobia Rational e : Claustro phobia is fear of closed space.

space or being a situation where escape is difficult. B. Socialph obia is fear of

performi ng in the presence of others in a way that will behumili ating or embarras sing. D.

Xenopho bia is fear of strangers 71. Answer: (A) Revealin g personal

informati on to the client Rational e : Counter transfere nce is an emoti

onal reaction of the nurse ont he client based on her unconsci ous needs

and conflicts. B and C. Theseare therapeut ic approach es. D. This is transfere

nce reaction where aclient has an emotiona l reaction towards the nurse

based on her past. 72. Answer: (D) Hold the next dose and obtain an order for a stat

serumlith ium level Rational e : Diarrhea and vomiting are manifest

ations of Lithium toxicity. The next dose of lithium should be withheld and test

is done to validatet he observati on. A. The manifest ations are not

due to drug interactio n. B.Cogen tin is used to manage the extra pyramida

l symptom side effects of antips ychotics. C. The common side effects of

Lithium are fine handtrem ors, nausea, polyuria and polydipsi a. 73.

Answer: (C) A living, learning or working environ ment. Rational e

:A therapeut ic milieu refers to a broad conceptu al approach inwhich all

aspects of the environ ment are channele d to provide atherape utic environ

ment for the client. The six environ mental elements include structure, safety,

norms; limit setting, balance and unitmodi fication. A. Behavior al

approach in psychiatr ic care is based on thepremi se that behavior can be learned

or unlearne d through the use of rewar d and punishm ent. B. Cognitiv

e approach to change behavior isdone by correctin g distorted

perceptio ns and irrational beliefs to correctm aladaptiv e behavior s. D. This is

not congruen t with therapeut ic milieu. 74. Answer: (B) Transfer ence

Rational e : Transfer ence is a positive or negative feeling associate

d with asignific ant person in the client‘s past that are unconsci ously

assigned toanother A. Splitting is a defense mechanis m commonl y seen in

a clientwit h personali ty disorder in which the world is perceive

d as all good or allbad C. Countert transfere nce is a phenome non where

the nurse shiftsfeel ings assigned to someone in her past to the patient

D. Resistan ce isthe client‘s refusal to submit himself to the care of the nurse

75. Answer: (B) Adventiti ous Rational e : Adventiti ous crisis

is a crisis involvin ga traumatic event. It isnot part of everyday life. A. Situation

al crisis is from an external sourceth at upset ones psycholo gical equilibri

um C and D. Are the same. Theyare transition al or develop mental

periods in life 76. Answer : (C) Major depressio n Rational e

: The DSMIV-TR classifies major depressio n as an Axis Idisorder .

Borderli ne personali ty disorder as an Axis II; obesity andhyper

tension, Axis III. 77. Answer : (B) Transfer ence Rational e

: Transfer ence is the unconsci ous assignme nt of negative or positiv

e feelings evoked by a significa nt person in the client‘s past toanother

person. Intellectu alization is a defense mechanis m in which theclient avoids

dealing with emotions by focusing on facts. Triangul ationrefe rs to conflicts

involvin g three family members . Splitting is a defense mechanis m

commonl y seen in clients with personali ty disorder in whichthe world is

perceive d as all good or all bad. 78. Answer : (B) Hypocho ndriasis

Rational have no e apparent : medical causes Complai are ns of character vague istic of physical clients symptom with s that hypocho

ndriasis. In manycas es, the GI system is affected. Conversi on disorders

are character izedby one or more neurolog ic symptom s. The client‘s

symptom s don‘tsug gest severe anxiety. A client experien cing sublimati

on channels maladapt ive feelings or impulses into socially acceptabl

e behavior 79. Answer : (C) Hypocho ndriasis Rational e

: Hypocho driasis in this case is shown by the client‘s belief thatshe has a

serious illness, although pathologi c causes have beenelim inated. The disturban

ce usually lasts at lease 6 with identifia ble lifestress or such as, in this

case, course examinat ions. Conversi on disorder sare character ized by

one or more neurolog ic symptom s.Depers onalizati on refers to persisten

t recurrent episodes of feelingde tached from one‘s self or body.

Somatof orm disorders generally have achronic course with few remissio ns.

80. Answer : (A) Triazola m (Halcion ) Rational e

: Triazola m is one of a group of sedative hypnotic medicati onthat can be

used for a limited time because of the risk of depende nce.Paro xetine is a

scrotonin -specific reutake inhibitor used for treatment of depres sion panic disorder,

Fluoxeti neis a scrotonin -specific reuptake inhibitor used for depressiv e disorders andobses sivecompulsi ve disorders . Answer : (D) It promotes emotiona l support or attention for the client .and obsessiv ecompulsi ve disorder. Risperid ome is indicated for psychoti cdisorder s. 81.

Rational e : Secondar y gain refers to the benefits of the illness that allowthe client to receive emotiona l support or attention. although some conflict is relieved. . Primary gain enablesth e client to avoid some unpleasa nt activity. A dysfuncti onal family maydisre gard the real issue.

82. Answer : (A) ―I went to the mall with my friends last Saturday be ‖ socially Rationa le : Clients with panic disorder tent to withdra wn. Goingto the mall is a sign of working .Somatof ormpain disorder is a preoccup ation with pain in the absence of physical disease.

Teachin g breathin g control is a major in terventi on for clients with panic disorder. The client taking medicati onsfor panic disorder .on avoidan ce behavior s. such as tricylic antidepr essants . Hyperve ntilating isa key sympto m of panic disorder.

and benzodi azepines .must be weaned off these drugs. 83. Answer and don‘t have nightma res‖ : (A) Rationa ―I‘m le sleeping :MAO better inhibitor . Most clients with panic disorder withago raphobia don‘t have nutrition al problem s.

MAO inhibitor s aren‘t used to help control flashbac ks or phobias or to decrease the craving for alcohol. 84.and intrusive daytime thoughts in individu al with posttrau matic stressdis order. Answer .s are used to treat sleep problem s. nightma res.

le: azepines Stoppin cancaus g a Stoppin e the benzodi g client to azepine antianxi have doesn‘t ety withdra tend to drugs wal cause such as sympto depressi .: (D) Stoppin g the drug can cause withdra wal sympto ms Rationa benzodi ms.

or decrease sleeping difficulti es.on. increase cognitiv e abilities. Answer difficulti es Rationa le : : (B) Adolesc Behavio ents ral tend to demonst rate severe irritabilit y andbeha vioral problem s rather than . 85.

Anxiety disorder is more common ly associat ed with small children rather than withadol escents.simply a depresse d mood. Labile mood is more characte ristic of a client with cognitiv eimpair ment or . Cognitiv e impairm ent is typically associat ed with delirium or deme ntia.

Cycloth .bipolar disorder. 86. Answer to major depressi on but of mild tomoder : (D) It‘s ate a mood severity disorder Rationa similar le : Dysthy mic disorder is a mood disorder similar to major de pression but it remains mild to moderat e in severity.

ymicdis order is a mood disorder characte rized by a mood range from moderat edepress ion to hypoma nia. Bipolar I disorder is characte rized by a singlem anic episode with no past major depressi ve episodes . Seasona laffective disorder is a .

87.form of depressi on occurrin g in the fall and winter. Answer abrupt onset : (A) Rationa Vascula le r : dementi Vascula a has r more dementi a differs from Alzheim er‘s disease in that ithas a more abrupt onset .

and runs a highly variable course. The inability to carry out motor activitie s is common inAlzhei mer‘s disease. 88. Personal lychang e is common in Alzheim er‘s disease. The duration of delirium isusuall y brief. Answer : (C) Drug intoxicat ion .

and diazepa m (a benzodia zepine). digoxin (a digitalis glycoxid e).furose mide (a thiazide diuretic). 89. Answer .S ufficient supportin g data don‘t exist to suspect the other options ascauses.Rational e : This client was taking several medicati ons that have apropens ity for producin g delirium.

which is a false sensory perceptio n. Flight of ideas is rapid . Dysarthri a is difficulty in speechpr oduction. Aphasiar efers to a communi cation problem.: (D) The client is experien cing visual hallucina tion Rational e : The presence of a sensory stimulus correlate s with thedefini tion of a hallucina tion.

Answer : (D) The client looks at the shadow on a wall and tells the nurseshe sees frighteni ng faces on the wall.shifting from one topic to another. 90. Rational e : Minor memory problems are distingui shed from dementia bytheir minor severity and their lack of significa nt interfere nce with theclient‘ .

Other options would be included inthe history data but don‘t directly correlate with the client‘s lifestyle. Answer : (D) Loose associati on Rational e : Loose associati ons are conversa tions that constantl y shift intopic. 91. Concrete thinking implies highly definitiv e thought .s social or occupati onal lifestyle.

processe s. paranoid personali tiesascrib e malevole nt activities . 92. Answer : (C) Paranoid Rational e : Because of their suspiciou sness. Flightof ideas is character ized by conversa tion that‘s disorgani zed from theonset. thenbeco mes loose. Loose associati ons don‘t necessari ly start in a cogently.

Clients with histrionic personali tydisorde r are dramatic. becomin gquarrels ome and argument ative. not suspiciou s and argument .to others and tent to be defensiv e. Clients with antisocia l personali tydisorde r can also be antagoni stic and argument ative but are lesssuspi cious than paranoid personali ties.

93.ative. Clients withschi zoid personali ty disorder are usually detached from other and tend tohave eccentric behavior. Answer : (C) Explain that the drug is less affective if the client smokes Rational e : Olanzapi ne (Zyprexa ) is less effective for clients who smokeci .

the client should be aware of adverse effects such as tardivedy skinesia. and extrapyra midal adverse reactions aren‘t a problem. 94. Serotoni n syndrom e occurs with clients who take acombin ation of antidepre ssant medicati ons. Olanzapi ne doesn‘t causeeup horia. However . Answer .garettes.

Clients with schizoty pal personali tydisorde r tend to be superstiti ous. Clients with histrionic personali tydisorde rs tend to overreact to frustratio ns and .: (A) Lack of honesty Rational e : l personali ty disorder tent to engage inacts of Clients dishonest y. shown with antisocia by lying.

selfblame and negative self evaluatio n will decrease.disappoi ntments. Clients with . and seek attention. havetem per tantrums. Answer : (A) ―I‘m not going to look just at the negative things about myself‖ Rational e : As the clients makes progress on improvin g selfesteem. 95.

These clients focus on self and aren‘t envious or jealous.depende ntperson ality disorder tend to feel fragile and inadequa te and would beextrem ely unlikely to discuss their level of compete nce and progress. Individu als withdepe ndent personali ty disorders don‘t take over situation s because .

Answer : (C) Assess for possible physical problems such as rash Rational e : Clients with schizoph renia generally have poor visceralr ecognitio n because they live so fully in their fantasy world. They need tohave as in-depth assessme nt of . 96.theysee themselv es as inept and inadequa te.

physical complain ts that may spill over into their delusion al symptom s. calling the physicia n to get the client‘s medicati onincrea sed doesn‘t address his physical . and itching isn‘t as adverse reaction of antips ychotic drugs. Talking with the client won‘t provide asassess ment of his itching.

Modelin g is the consciou s copying of someo ne‘s behavior s. Egosyntonici ty refers to behavior s that correspo ndwith . 97.complain ts. Answer : (B) Echopra xia Rational e : Echopra xia is the copying of another‘s behavior s and is theresult of the loss of ego boundari es.

Answer : (C) Hallucin ation Rational e : Hallucin ations are sensory experien ces that aremisre presentat ions of reality or have no basis in reality.the individua l‘s sense of self. Ritualis m behavior s are repetitive andcomp ulsive. Delusion s arebelief s not based in reality. . 98.

a return to earlier behavior to reduce anxiety. An idea of refere nce is a belief that an unrelated situation holds special meaning for the client.Disorgan ized speech is character ized by jumpi ng from one topic to the next or using unrelated words. Answer : (C) Regressi on Rational e : Regressi on. . 99.

Projectio n is a defense mechanis m in which one blames others and attempts to justify actions. Rationali zation is a defense mechanis m used to justify one‘sacti on.isthe basic defense mechanis m in schizoph renia. Repressi . it‘sused primarily by people with paranoid schizoph renia and delusion aldisorde r.

Answer : (A) Should report feelings of restlessn ess or agitation at once Rational e : Agitatio n and restlessn ess are adverse . or experien ces fromawa reness.10 0. it‘s an involunta ry exclusio n of painful thoughts.on is the basic defense mechanis m in the neuroses. feelings.

Althoug h theclie nt may experien ce increase d concentr ation and activity. not the drug itself.effect of haloperi doland can be treated with antochol inergic drugs. Haloperi dol isn‘t likely tocause photose nsitivity or contr ol essent ial hyper tension. . these effectsar e due to a decrease d in symptom s.

NUR SING 1. minat H o s t .Whi FOU ch ele NDA ment i TION n OF the cir cular ed chain bypres of infe erving ction skin can integri be eli ty?a .

b.W hich of the follow ing will proba bly result in a brea k in sterile techni que for res pirator y .P ortal of ent ry2.Res ervoi r c.M ode of trans missi ond.

isolati on?a.Tur ning on the pa tient‘s room ventil ator c. Openi ng the door of the patien t‘s roo m lea . Openi ng the patien t‘s windo w to the outsid e enviro nment b.

Whic h of the fol lowin g patien ts is at gre ater ri sk for co .ding i nto the hospit alcorri dor d. Failin g to wear glove s when admin isterin ga bed bath3.

A patien t receiv ing broad posto perati spectr ve um patien antibi t who oticsc.A patien t with leuko penia b.ntracti ng aninfe ction? a. has un A dergo .

A newly diagn osed d diabet washi ic pati ngreq ent uires orthop edic s urgery d.S oap or deterg ent to prom ote emuls ificati . the Effecti use vehan of:a.

A disinf ectant to increa se surfac e tensio nd.hand washi .onb. After routin e patient contac t.H ot wat er to destro y bacter iac.Al l of the a bove 5.

2 min uted. 3 mi nutes 6.Whi ch of the fol lowin g proce dures alway s requir es surgic al asepsi s?a.30 s econ dsb.1 minu tec.ngsho uld last at least:a .V .

Urinar y cathet erizati on c. Nasog astric tube inserti on d. Colost omy irrigati on7.St .aginal instill ation of conju gated estrog en b.

erile t echni que is used when ever:a .Strict

isolati on is requir edb.T ermin al disi nfecti

on is perfor medc. Invasi ve proce dures

are pe rform edd.P rotecti ve iso lation is nec

essary 8.Whi ch of the fol lowin g consti

tutes a brea k in ster ile techni que w

hilepr eparin ga sterile field for a dressi

ng chang e?a.U sing sterile forcep s, rath

er sterile than item sterile b.Touchi ng the gloves outside , wrapper of sterili to han zed mate dle a rial with

out steril eglovesc. Placing a sterile object on the edge of the sterile fieldd.Po

uring out a small amount of soluti on (15 to 30 ml) befo re pouringt he

solution into a sterile container 9.A natural body defense that plays an

active role in preventi ng infection is:a.Ya wningb .Body h air c.Hi ccuppin

gd.Rapi d eye moveme nts 10. All of the followin g statemen

t are true aboutdon ning sterile glovesex cept:a.Th e first glove should b e picked

up by grasping the insid e of thecuff.b .The second glove should be picke

d up by insert ing the glovedfi ngers under the cuff outside the glove.c.

The gloves should be adjust ed by sliding the gloved fingers under th

e sterile cuff and pulling the glove over the wristd.T he inside of the glove is

consider ed sterile11 .When removin ga contamin ated gown, the nurse

should be careful thatthe first thing she touches is the:a.Wa ist tie

and neck tie at the back of the gownb. Waist ti e in front of the gownc.

Cuffs of the go wnd.Ins ide of th e gown12. Which of the followin g nursing

intervent ions is consider ed the mosteffe ctive form or universal precautio ns?a.Cap

all used needles before removin g them from their syringes b.Discar d all

used uncappe d needles and syringes in animpen etrable protectiv

e container c.Wear gloves when administ ering IM injection sd.Follo w

enteric precauti ons13.Al l of the followin g measures are recomme nded to

prevent pressure ulcersexc ept:a.Ma ssaging the redd ened are with lotionb. Using a

water or air mattress c.Adheri ng to a schedule for positioni ng and turningd

.Providi ng metic ulous ski n care14. Which of the followin g blood tests

should be performe d before a bloodtra nsfusion ?a.Proth rombin a nd coag

ulation t imeb.Bl ood typing a nd cross matchin gc.Blee ding and

clotting time d. Complet e blood count (CBC)an d electrolyt e

levels.15 .The primary purpose of a platelet count is to evaluate the:a.Pot

ential for clot formatio nb.Pote ntial for blee ding c.Presen ce of an antig

enantibody response d.Presen ce of cardiac enzymes 16.Whic h of the followin

g white blood cell (WBC) counts clearly indicates leukocyt osis?a.4, 500/mm

³b.7,00 0/mm³c .10,000 /mm³d. 25,000/ mm³ 17. After 5 days of diuretic

therapy with 20mg of furose mide(Las ix) daily, apatient begins to exhibit fatigue,

muscle cramping and muscle weaknes s.These symptom s probably indicate

that the patient is experien cing:a.H ypokale miab.H yperkal emiac. Anorex iad.Dys

phagia1 8.Which of the followin g statemen ts about chest Xray is false?a.

No contradi ctions exist for this testb.Bef ore the procedur e, the patient s

hould re move all jewelry, metallic objects, and buttons above the waistc.A

signed consent is not required d.Eating, drinking , and medicati ons are allow

ed befor e this test19.Th e most appropri ate time for the nurse to obtain a sputum

specimen for cultur e is:a.Earl y in the morning b.After the patient eats a

light breakfas tc.After aerosol therapy d.After chest physioth erapy20. A patient

with no known allergies is to receive penicillin every 6 hours.W hen administ

ering the medicati on, the nurse observes a fine rash on thepatien t‘s skin. The most

appropri ate nursing action would be to:a.Wit hhold the moderati on and

notify the physicia nb.Admi nister the medicati on and notify the

physicia nc.Admi nister the medicati on with an antihista mined.A pply

corn starch soaks to the rash21.A ll of the followin g nursing intervent ions are

correct when using the Z-track method of drug injection except:a. Prepare the

injection site with alcoholb .Use a needle t hat‘s a least 1‖ longc .Aspirat e for

blood be fore inje ctiond.R ub the site vigorous ly after the injection to promo

te absorp tion22.T he correct method for determin ing the vastus lateralis

site for I.M.injec tion is to:a.Loc ate the upper aspect of the upper outer qu

adrant of the butto ckabout 5 to 8 cm below the iliac crestb.Pa lpate the lower edge of

the acro mion pro cess and the midp ointlater al aspect of the arm c.Palpat e a 1‖

circular area anterior to the umbilicu sd.Divid e the area bet ween the greater

The middeltoid injection site is seldom used for I.M.Can be used only wh en the patient .Bru ises too easil yc.femoral t rochante r and thela teral femoral condyle into thirds.Can accomm odate only 1 ml or less of medicati onb. inje ctions because it:a. and select the middle third on theanteri or of the thigh23.

is lying downd.Par . 2 0 Gb. 1 ½‖ lo ngb.18G . The appropri ate needle gauge for intrader mal injection is:a . 1 ½‖ longd. 5/8‖ long25.22 Gc. Does not readily parenter al medicati on24. 1‖ longc.26 G 26.25 Gd.Th e appropri ate needle size for insulin injection is:a.2 5G.2 2G.22 G.

6 mgb. 60 mg .IV or a n intrade rmal injection c. The equivale nt dose inmilligr ams is:a .Intrade rmal or subcutan eous injection d.1 0 mgc.The physicia n orders gr 10 of aspirin for a patient.IM or a subcuta neous injectio n27.enteral penicilli n can be administ ered as an:a.IM injectio n or an IV solution b. 0 .

What would the flow rate be if the drop factor is 15 gtt = 1 ml?a.T he physicia n orders an IV solution of dextrose 5% in water at100ml/ hour.25 gt t/minut ed.5 g tt/minut eb.Whi ch of the followin g is a sign or symptom of a hemolyti c reaction toblood .13 gt t/minut ec.600 m g 28.d.50 gt t/minut e29.

Chr onic Obs tructive Pulmona ry Disease c.transfusi on?a.He moglobi nuriab. Chest p ainc.Dehy dration3 1.Ur ticariad . F e v e r b. Which of the followin g condition s may require fluid restrictio n?a .All of the followin g are common signs and symptom s of . Renal Failure d.Distend ed neck veins30.

Ask . Pain or discomf ort at the IV insertion siteb.Ed ema and war mth at the IV insertion sitec.Fra nk bleeding at the in sertion site32.T he best way of determin ing whether a patient has learned to instill ear medi cation properly is for the nurse to:a.A red streak ex iting the IV insertion sited.phlebitis except:a.

Whi ch of the followin g types of medicati ons can be .the patient if he/she has used ear drops beforeb. Have the patient repeat the nurse ‘s instruc tions using her own wordsc. Demonst rate the procedur e to the patie nt and encourag e to askquesti onsd.As k the patient to demonst rate the procedur e33.

A ny oral medicati onsb. Entericcoated ta blets that are thor oughly dissolve d in water d.A patient who develops hives after receiving .Ca psules whole contents are dissolve in water c.administ ered viagastro stomy tube?a. Most tablets designed for oral use. exce pt for extended duration compoun ds34.

Toleran ceb. All of thefollo wing are appropri ate nursing intervent ions except:a. popliteal .Syne rgismd. Allergy 35. Assess f emoral.Idio syncras antibiotic is exhibitin gdrug:a. and pedal pulses every 15 minut es for 2hoursb.A patient has returned to his room after femoral arteriogr aphy. .

The nurse explains to a patient that a cough:a.Check the pressure dressing for sanguine ous drainage c.Assess a vital signs every 15 minutes for 2 hoursd. Order a hemoglo bin and hematoc rit count 1 hour after thearteri ography3 6. Is a protectiv e respon se to clear the respi ratory tract of irritantsb .

.Is induced by the administ ration of an antitussi ve drugd. The best nursingin terventio n is to:a.App ly iced alcohol sponges b.Provid e increas ed cool l iquidsc.An infected patient has chills and begins shivering .Is primaril ya voluntar y action c.C an be inhibited by ―splintin g‖ the abdome n37. .

A clinical nurse specialis t is a nurse who has:a.Provide addition al bedcloth esd.Prov ide incre ased ven tilation 38.Gr aduated from an associat e degree .Be en certifie d by the Nationa l League for Nursing b.Recei ved credenti als from the Phil ippine Nurses‘ Associa tionc.

Cha nge the .De crease burning sensatio nsb.39 .The purpose of increasi ng urine acidity through dietary means is to:a. Comple ted a master‘s degree in the pres cribed clinical area and isa registere d professi onal nurse.progra m and is a registe redprofe ssional nursed.

Change the urin e‘s conc entratio nd.Inhi bit the growth of microor ganisms 40.urine‘s color c.Clay colored stools indicate :a. An effe ct of medicat iond.Imp ending constip ationc.Bi le obstr uction4 1.In which step of the nursing process would .Uppe r GI bleedin gb.

White potatoe sb.Al l of the followin g are good sources of vitamin A except:a .Car rotsc. . Evaluati on42.the nurse ask a patient if themedi cation she administ ered relieved his pain? a. Assessm ent b.A nalysis c. Plannin g d.

Irrigat e the patient with 1% .Aprico tsd.Eg g yolks4 3.Which of the followin g is a primary nursing interven tion necessar y for allpatien ts with a Foley Catheter in place?a. Maintai n the drainag e tubing and collecti on bag level with thepatie nt‘s bladder b.

Neospor in soluti on three times a dailyc. Clamp the catheter for 1 hour every 4 hours to maintai n thebladd er‘s elasticit yd. .The ELISA test is used to: a.Main tain the drainag e tubing and collecti on bag below b ladder l evelto facilitate drainage by gravity4 4.

Aid in diagnosi ng a patient withAI DSd.Th e two blood vessels most common ly used .Al l of the abo ve45. Test blood to be used for transfus ion for HIV antibodi es c.Screen blood donors for antibodi es to human immuno deficien cyvirus( HIV)b.

Shavi ng the site on the day . which n veins Effective of the skin c.Femor disinfecti al and on before subclavi a an surgical veinsd. Brachia l and su femoral includes bclavia veins46.Su bclavia n and jugular veinsb.for TPN infusion are the:a. procedur Brachial e and followin g methods ?a.

before surgeryb .Havin g the patient take a tub bath on the morning of surgeryd .When transferri ng a patient from a bed to a .Applyin ga topical antisepti c to the skin on the eveni ng befor esurgery c.Having the patient shower with an antisepti c soap on the eveningv =before and the morning of surgery4 7.

Incr eases partial thrombo plastin timeb. Abdomi nal muscles b.chair.Back muscles c.A cute pul sus paradox usc.An impaired . Upper arm mu scles48.Leg m usclesd. Thrombo phlebitis typically develops in patients with which of the followin gconditio ns?a. the nurse should usewhich muscles to avoid back injury?a.

Res piratory acidosis. lung ventilatio n can become altered.App neustic .In a recumbe nt. and hypostati c pneumo niab.C hronic Obstruct ive Pulmona ry Disease (COPD) 49.or traumati zed blood vessel walld. immobili zed patient.le ading to such respirato ry complica tions as:a. ateclect asis.

resulting in such disorders asa.Immob ility impairs bladder eliminati on. causing incontine nceb.Kuss mail‘s respirati ons and hypoven tilation5 0.Che yneStrokes r espiratio ns and s pontaneo us pneu mothora xd.Incre ased urine aci dity and relaxatio n of the perineal muscles.breathin g. atypic al pneum onia and respirato ry alkalo sisc.Uri .

RATIO D NALE . bladder distentio n. and infection c. Decreas ed calcium and phospha te levels in the urine DATIO N OF ANSW NURSI ERS NG AND 1. and decrease d urine specific gravityd.Diures is. natriures retention . In the – circular FOUN chain of .

2.infectio n. Respirat ory isolation . pathoge ns must be able to leave their res ervoir and be transmit ted to a suscepti ble host through a portal of entry. such as broken skin. like strict isolation . C . requires that the door to thedoor patient‘s room .

Howeve r. so opening the window or turning on the ventricu lar isdesira ble. The nurse does not need to wear gloves for respirato ryisolati on. but good hand washing is importa nt for all types of . the patient‘s room should bewell ventilate d.remain closed.

Leukope nia is a decrease d number of leukocyt es (white blood cells).isolation . None of the other situation swould put the patient at risk for contracti ng an infectio n. A .w hich are importa nt in resisting infectio n. 3. taking broadspectru .

Soaps and detergen ts are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsify ingagent s. 4. A . Hot water may lead to skin irritation .m antibioti cs might actually reduce the infectio n risk.

After routine patient contact. 5. handwas hing for 30 seconds effective ly minimiz es the risk of pathoge ntransmi ssion. hand washing may last from 10 seconds to 4 minutes. Dependi ng on the degree of exposur e to pathoge ns. A . .or burns.

The urinary system is normall y free of microor ganisms except at theurina ry meatus. B . 7. All invasive . Any procedu re that involves entering this system mustuse surgicall y aseptic measure s to maintain a bacteriafree state. C .6.

and the nurse and thephysi cian must wear sterile gloves . includin g surgery. require sterile techniqu e to maintain asterile environ ment.procedu res. catheter insertion . andadmi nistratio n of parenter al therapy. All equipme nt must be sterile.

the nurse and physicia n are required to wear sterilego wns.g owns and . masks. Strict isolation requires the use of clean gloves. hair covers. masks.and maintain surgical asepsis. In theopera ting room. and shoe covers for all invasive procedu res. gloves.

equipme nt to prevent the transmis sion of highly commun icabledi seases by contact or by airborne routes. Termina l disinfect ion is thedisinf ection of all contami nated supplies and equipme nt after a patient hasbeen discharg ed to prepare them for reuse by another .

8. C . The edges of a sterile field are consider ed contami nated.patient. Thepurp ose of protecti ve (reverse ) isolation is to prevent a person withseri ously impaire d resistanc e from coming into contact who potential lypathog enic organis ms. .

B . 9. the sterileite ms also become contami nated. Hair on or within body areas.When sterileite ms are allowed to come in contact with the edges of the field. Yawnin g and . such as the nose. traps and holdspar ticles that contain microor ganisms.

hiccuppi ng do notpreve nt microor ganisms from entering or leaving the body. but not sterile 11. D . . The inside of the glove is always consider ed to be clean. 10. Rapid eyemov ement marks the stage of sleep during which dreamin g occurs.

turn and fold .A . the nurse should untie theback of the gown.So. The back of the gown is consider ed clean. after removin g gloves and washing hands. holding theinside of the gown and keeping the edges off the floor. slowly move backwar d away from the gown. the front is contamin ated.

12. blood-tobloodcon tact occurs most commonl y when a health care worker attempts to capa used needle. discard it in a contamin ated linen container . Therefor e. then washher hands again. Accordin g to the Centers for Disease Control (CDC). B .thegown inside out. used needles .

should never be recapped . injection. Wearing gloves is not always necessar y whenad ministeri ng an I. labeled container .instead they should be inserted in a specially designed puncture resistant. Enteric precautio ns prevent the transfer of pathog ens via feces.M. A . 13. Nurses and other .

research has shown that massage only increases the likelihoo d of cellular ischemia and necrosis to the care professio nals previousl y believed thatmass aging a reddened area with lotion would promote venous return andreduc e edema to the area. 14. B . However .

. Before a blood transfusi on is performe d. the blood of the donor andrecipi ent must be checked for compatib ility. This is done by blood typing (atest that determin es a person‘s blood type) and crossmatching (aproced ure that determin es the compatib ility of the donor‘s and recipient ‘sblood after the .

A platelet count determin es the number of thrombo cytes in blood available . If the blood specimen s areincom patible. hemolysi s and antigenantibody reactions will occur. Platelets are diskshaped cells that are essential for blood coagulati on. 15. A .blood types has been matched) .

The normal count ranges from 150. A count of 100.It also is used to evaluate the patient‘s potential for bleeding. however. thisis not its primary purpose.000 to350.for promotin g hemostas is and assisting with blood coagulati on after injury.00 0/mm 3 .000/ mm 3 or less indicates a .

16. 3 Leukocyt is osis is associate any transient increase in the number of white bloodcell s (leukocyt es) in the blood. Normal WBC counts range from 5.000 to100.potential for bleed ing. D . count of less than 20.00 0/mm 3 .000/ mm d with spontane ousbleed ing.

Fatigue. and 3 muscle indicates weaknes leukocyt ses are osis. which is a potential sideeffec t of diuretic therapy.. s A of hypok alemia (an inadequa te potassiu m level).000/ mm . symptom 17. Thus. a count of 25. The physicia n usually orders supplem entalpota ssium to . muscle cramping .

A . Pregnanc y or suspecte d pregnanc y is the only contraind ication for achest Xray. Dysphag ia means difficulty swallowi ng. if a chest Xray is necessar y. the patient . However . Anorexia is another symptom of hypokale mia.prevent hypokale mia in patients receiving diuretics. 18.

Eating. and buttons would interfere with the X-ray and thus should not beworn above the waist. Jewelry.can wear a lead apron to protect the pelvic region from radiation. A signed consent is not required because a chest X-ray is not an invasive examinat ion. metallico bjects. drinking and .

20. 19. Obtainin ga sputum specimen early in this morning ensures anadequa te supply of bacteria for culturing and decrease s the risk of conta mination from food or medicati on.medicati ons areallow ed because the X-ray is of the chest. A . A . not the abdomin al region.

who may choose to substitut e another drug. Because of the danger of anaphyla ctic shock.even in individua ls who have not been allergic to it previousl y. he nurse should withhold the drug andnotif y the physicia n.. Initial sensitivit y to penicillin is commonl y manifest ed by a skin rash.Ad ministeri .

it is not the nurse‘s top priority in such apotentia lly life- threateni ng situation. .M. D . 21. Although applying corn starch to therash may relieve discomfo an antihista mine is a depende nt nursing intervent ion thatrequi res a written physicia n‘s order. The Ztrack method is an I.

therebym inimizin g skin staining and irritation.injection techniqu e in which the patient‘s skin is pulled in such a way that the needle track is sealed off after theinjecti on. Rubbing the injection site iscontrai ndicated because it may cause the medicati on to . This procedur e seals medicati on deep into the muscle.

The vastus lateralis.T he middle third of the muscle is . 22.extravasa te intothe skin. a long.injec tions because it has relatively few major nerves and blood vessels. D .M. is viewed by many clinician s as the site of choice for I. thick muscle that extends the full length of the thigh.

23. close to the .recomme nded as the injection site. Thepatie nt can be in a supine or sitting position for an injection into this site. The middeltoid injection site can accomm odate only 1 ml or less of medic ation because of its size and location (on the deltoid muscle of thearm. A .

1 ½‖needl e is usually used for I.brachial artery and radial nerve). D .M. injection s in children. 24. typically in the vastuslat eralis. An 18G. 1 ½‖ needle is . A 22G. 5/8‖ needle is the recomme nded size for insulin injection because insulin is administ ered by the subcutan eous route. A 25G.

whichare typically administ ered in the vastus lateralis or ventrogl uteal site. a small- bore 25G needle is recomme nded.M. injection s. D . 25. Because an intrader mal injection does not penetrate deeply into theskin.usually used for adult I. This type of injection isused primarily to .

M.M.administ er antigens to evaluate reactions for allergy or sensiti vity studies. 26. a 22G needle for I. and a 25G needle. and a 25G needle. for subcutan eous insulin injection s. injection s. injection s of oilbased medicati ons. for I.M. . A 20G needle is usually used for I. injection s.

C .M. 100ml/6 0 min X 15 gtt/ 1 ml = 25 gtt/minut e 29. A . It cannot be administ ered subcutan eously or intrader mally. or added to a solutiona nd given I. 27. D . Parentera l penicillin can be administ ered I. gr 10 x 60mg/gr 1 = 600 mg 28.A .V.

.ind icates a hemolyti c reaction (incompa tibility of the donor‘s andrecipi ent‘s blood). In this reaction. Hemoglo binuria. the cells are hemolyz ed in either circulato ry or . antibodie s in the recipient ‘s plasmaco mbine rapidly with donor RBC‘s. the abnormal presence of hemoglo bin in the urine.

C .reticuloe ndotheli al system. Hemoly sis occurs more rapidly inABO incompa tibilities than in Rh incompa tibilities. Chest pain and urticaria may be sympto ms of impendi ng anaphyl axis. 30. Distend ed neck veins are anindica tion of hypervo lemia.

In real failure. the kidney loses their ability to effective ly eliminat ewastes and fluids. chronic obstructi ve pulmona rydiseas e. Fever.V. fluids may be necessar y. Because of this. and dehydrat ion are conditio ns for .. limiting the patient‘s intake of oral andI.

the inflamm ation of a vein. solution s or medicati ons). 31. or a . can be caused by chemica lirritants (I. mechani cal irritants (the needle or cathet er used during venipun cture or cannulat ion).V.which fluids should beencou raged. D . Phlebitis .

insertion site.V. and ared streak going up the arm or leg from the I. D . edema and heat at the I. Return demonst . 32.V. insertion site.localize d allergicr eaction to the needle or catheter. Signs and sympto ms of phlebitis include pain or discomf ort.

D . Capsule s. and most extende d duration or sustai ned release products should not be dissolve d for use in agastros . 33. entericcoated tablets.ration provides the most certain evidenc e for evaluati ngthe effective ness of patient teaching .

They are pharmac eutically manufac tured in these formsfor valid reasons. and altering them destroys their purpose. 34. The nursesh ould seek an alternate physicia n‘s order when an ordered medicati on isinappr opriate for delivery by tube.tomy tube. D .

A drugallergy is an adverse reaction resulting from an immuno logicres ponse followin ga previous sensitizi ng exposur e to the drug. Toleran ce to a drug means that the patient .. Thereact ion can range from a rash or hives to anaphyl actic shock.

or other substanc e. food. it appears to be genetica lly determi ned. Idiosync rasy is an individu al‘s unique hyperse nsitivity to a drug. Synergis m .experien ces a decreasi ng physiolo gicrespo nse to repeated administ ration of the drug in the same dosage.

The other answers are . 35. D . is adrug interacti on in which the sum of the drug‘s combine d effects is greater t han that of their separate effects..A hemoglo bin and hematoc rit count would be ordered by the physicia nif bleeding were suspecte d.

a protecti ve response that clears the respirato ry tract of irritan ts. Coughin g. A . 36. usually is involunt ary. as when . however it can be voluntar y.appropri ate nursingi ntervent ions for a patient who has undergo ne femoral arteriogr aphy.

shiverin g results from the body‘s attempt .apatient is taught to perform coughin g exercise s. Splintin g the abdome n supports the abdomin al muscles when a patient coughs. In an infected patient. C . An antitussi ve druginhi bits coughin g. 37.

Applyin g addition al bed clothes helps to . Initial vasocon striction may cause skin to feel cold to thetouch .toincrea se heat producti on and the producti on of neutrop hils andphag ocytotic action through increase d skeletal muscle tension andcontr actions.

D .master‘s degree in . A increased aclinical temperat clinical metabloi specialty ure and nurse sm. result in equalize further s 38. and and be a stop the specialist thus registere chills. the body hivering. nurse. must increased d Attempts have heat professio to cool complete producti nal the body d a on.

The National League of Nursing accredits educatio nal programs in nursing and provides a testing service to evaluate student nursing compete nce but it does notcertif y nurses. The America n Nurses Associati on identifies requirem entsfor certificati on and offers examinat ions for certificati on in many .

such as medical surgical nursing. These certificati on(crede ntialing) demonstr ates that the nurse has the knowled ge and theability to provide high quality nursing care in the area of her certificati on. Agraduat e of an associate degree program is not a clinical nurse specialist :however .areas of nursin g.. she is prepared .

Microorg anisms usually do not grow in an acidic environ ment. D .to provide bed side nursing with a high degreeof knowled ge and skill. D . 39. Bile colors . She must successf ully complete the licensing examinat ion to become a registere d professio nal nurse. 40.

Constipa tion ischaract erized by small. drugs .the stool brown.Up per GI bleeding results in black or tarry stool. hard masses. claycolored stool. Any inflamm ation or obstructi on that impairsbi le flow will affect the stool pigment. yielding light. Many medicati ons and foods willdisco lor stool – for example.

beetsturn stool red. 41.. 42. A . D . The main sources of vitamin A are . the nurse must decidew hether the patient has achieved the expected outcome that wasident ified in the planning phase. In the evaluatio n step of the nursing process.containin g iron turn stool black.

collard greens. spinach. Maintain g the drainage tubing and . butter. Animals ources include liver. kidneys. 43. cream.yellow and green vegetabl es (suchas carrots. and cantalou pe). D . broccoli. and egg yolks. andcabba ge) and yellow fruits (such as apricots. sweet potatoes. squash.

The ELISA test of venous blood is used to assess blood . 44. D .collectio n bag level with the patient‘s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neospori n and clamping the catheter for 1 hour every 4 hours mustbe prescribe d by a physicia n.

A positive ELISAte st combine d with various signs and symptom s helps to diagnose acquired immuno deficienc y syndrom e (AIDS) 45.and potential blood donors to human immuno deficienc y virus (HIV). Tachypn ea (an abnormal ly rapid rate of breathing ) would indicate thatthe patient was still hypoxic . D .

46.Eu pnea refers to normal respiratio n.(deficien t in oxygen). The partial pressures of arteria l oxygen and carbon dioxide listed are within the normal range. Studies have shown that showerin g with an antisepti c soap beforesur gery is the most effective method of removin g . D .

if indicated . Shaving the site of the intended surgery might cause breaks in theskin.shaving. should be done immediat ely before surgery. however. A topical antisepti c would not remove microorg anisms and .microorg anisms from theskin. thereby increasin g the risk of infection . not the day before.

47. Muscles of the abdomen .would bebenefi cial only after proper cleaning and rinsing. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. C . Tub bathing mighttra nsfer organism s to another body site rather than rinse them away.

The factors. bloodhyp ercoagul ability. 48. C . collectiv ely predispo se a patientto thrombo plebitis. Increase d partialthr ombopla stin time indicates a . impaired venous return to the heart.. known as Virchow ‘s triad. back. and injury to a blood vessel wall. and upper ar ms may be easily injured.

49. A . Arterialb lood disorders (such as pulsus paradoxu s) and lung diseases (such asCOPD ) do not necessari ly impede venous return of injure vessel walls.prolonge d bleeding time during fibrin clotform ation. Because of . commonl y the result of anticoag ulant (heparin) therapy.

atelectasi s from reduced surfactan t and accumul ated mucus inthe bronchio les. and hypostati c pneumon ia from bacterial growth causedby stasis of mucus . immobili zepatient is at particula r risk for respirato ry acidosis from poor gasexcha nge.restricted respirato ry moveme nt. a recumbe nt.

50. which provide an excellent medium for bacte rial growth leading to infection. Immobili ty also results in morealka .secretion s. This leads to bladder d istention and urine stagnatio n. B . The immobili zed patient commonl y suffers from urine retention causedby decrease d muscle tone in the perineum .

line urine with excessiv e amounts of calcium.a gradual decrease in urine producti on. MATER NAL AND CHILD HEALT H 1. the nurse informs the clientabo ut the need to take the . sodium and phosphat e. and an increased specific gravity.For the client who is using ora l contrace ptives.

Main tain hormon al levelsc. Reduce side eff ectsd.pill at the same time each day to accompli shwhich of the followin g?a. W hich of the followin g wouldthe nurse include as the .Decr ease the incidenc e of nause ab.Wh en teaching a client about contrace ption.Pr event drug interacti ons2.

Diaph ragmb.Va sectom y3.Sper micides b. Condo msd.When preparin ga woman who is 2 days postpart um for disch arge.most effective method for preventin g sexuallyt ransmitte d infection s?a. .Diaph ragmc.reco mmendat ions for which of the followin g contrace ptive methods wouldbe avoided? a.

Nullipar ous womanc . Rhythm method 4. A .P ostpartu m client5.Female condom c. For which of the followin g clients would the nurse expect that anintraut erine device would not be recomme nded?a. Woman over age 35b.Promis cuous young adultd.Oral contrace ptivesd.

―I ‘m constipat ed all the time!‖W hich of the followin g should the nurse recomme nd?a.Decre ased flui d intake6.L axative sc.Da ily ene masb.Incre ased fib er intake d.client in her third trimester tells the nurse. Which of the followin g would th e nurse use as the basis for the teaching plan when caring .

A total gain of 25 to 30 pounds7 .1 pound per week for 40 weeksc.for a pregnant teenager concerne d about gaining toomuch weight during pregnanc y?a. ½ pound per week for 40 weeksd.The client tells the nurse that her last menstrua l period st arted on January1 4 and .10 p ounds per trim ester b.

―I hada son born at 38 weeks gestation .Octob er 21c. the nurse determin esher EDD to be which of the followin g?a. Using Nagele‘s rule.ended on January 20.Sept ember 27 b. Novem ber 7d.a daughter born at 30 weeks .When taking an obstetric al history on a pregnant client wh o states.Dec ember 2 78.

thenurse would .Wh en preparin g to listen to the fetal hea rt rate at 12 weeks‘ gestation .gestation and I lost a baby at about 8 weeks.G3 T2 P0 A0 L2d.G2 T2 P0 A0 L2b.G3 T1 P1 A0 L2c.‖ the nurse should record her obste trical history as which of the followin g?a.G4 T1 P1 A1 L29.

Stet hoscope placed midline at the umbilicu sb.Whe n developi ng a plan of care for a .Dopp ler placed midline at the suprapu bic regionc. External electroni c fetal m onitor pl aced at the umbilicu s10. Fetoscop e placed midway between the umbi licus and the xiphoidp rocessd.use which of the followin g?a.

A client at 24 weeks gestation has gained 6 pounds in 4 weeks.client newly diagnose d withgest ational diabetes.Diet ary intakeb. Which of the followin g would be the priority when assessing . which of the followin g instructio ns would be thepriorit y?a. Glucose monitor ing11. Medicat ionc.Ex ercised.

D epressi onc. Speculu mexamin ation reveals 2 to 3 cms cervical dilation. Glucos uriab.Han d/face e demad.the client?a. Dietary intake1 2. The nurse woulddo cument these findings .A client 12 weeks‘ pregnant come to the emergen cy departme nt withabdo minal cramping and moderate vaginal bleeding.

Befor e .Kno wledge Deficitd .Thre atened a bortionb .Misse d aborti on13.Immine nt abortion c. P a i n c.Risk for infectio nb .W hich of the followin g would be the priority nursing diagnosis for a clientwit h an ectopic pregnanc y? which of the followin g?a.Compl ete abortion d.Anticip atory Gr ieving 14.

Assist her to ur inate15.A mbulate her in th e halld. Which of the followin g should the nurse do when . Adminis ter analg esiac. which of the followin g should thenurse do first?a.A ssess the vital signsb.assessing the postpartu m client‘s uterus for firmness and positioni n relation to the umbilicu s and midline.

Use soap and water to clean the nipples1 6.Adm inister a narcotic before breast feedingc .a primipar a who islactatin g tells the nurse that she has sore nipples?a .Encoura ge her to wear a nursing brassiere d. 4 hours‘ postpartu m that areas .Tell her to breast fe ed more frequent lyb.The nurse assesses the vital signs of a client.

R 20per minute. Which of the followin g should the nurse do first?a.R eport the temperat ure to the physicia nb.4ºF. thready.follows: BP 90/60.Rech eck the blood pressure with another cuff c. temperat ure 100.A ssess the uterus fo r firmness and position d. pulse 100 weak.Deter mine the amount .

Which of the followin g assessme nts would warrant notificati on of the physicia n?a. A pink to brownis h discharg e on a client .A dark red discharg e on a 2day postpart um clientb.of lochia17 .The nurse assesses the postpartu m vaginal discharg e (lochia) on four clie nts.

A bright red discharg e 5 days after delivery 18. with a uterus that istender when palpated. remains unusuall y large. and not descendi ng asnormal ly .Al most col orless to creamy discharg e on a client 2 weeks after deli veryd.A postpartu m client has a temperat ure of 101.4ºF.who is 5 days postpart umc.

Which of the followin g should the nurse assess next?a.Incisi ond . Breasts c. .expected.L ochiab.W hich of the followin g is the priority focus of nursing practice with thecurren t early postpartu m discharg e?a. U r i n e 19.Pro moting comfort and restorati on of healthb. Explorin g the emotion al status of the familyc.

Te aching about the importa nce of family planning 20. Which of the followin g actions would be l east effective in maintaini ng aneutral thermal environ ment for the newborn ?a.Facilitati ng safe and effective self-and newborn cared.Placi ng infant under radiant warmer after bathingb .

Coverin g the scale with a warme d blanket prior to weighin gc.Tali .A newborn who has an asymmet rical Moro reflex response should befurther assessed for which of the followin g?a.Coveri ng the infant‘s head with a knit stockine tte21..Placi ng crib close to nursery window for family viewing d.

Fractu red clavicle c.Dis comfort d. assessing for which of the followin g is the priority? a.Infect ionb.Increa sed intra cranial p ressure2 2.The mother asks the nurse.Dehy dration2 3.Conge nital hypothy roidism d.He morrha gec.pes equi novarus b. ―What‘s wrong .During the first 4 hours after a male circumci sion.

―Yo u should discuss this with you .with my son‘s breasts? Whyare they so enlarged ?‖ Whish of the followin g would be the best response by the nurse?a.― A decrease in material hormone s present before bi rth causesen largemen t.‖c.― The breast tissue is inflam ed from the trauma experien ced with birth‖b.

mild intercost alretracti ons. and grunting at the end of expiratio n.Immed iately after birth the nurse notes the followin g on a male newborn: respiratio ns 78. It could be a maligna ncy‖d. apical hearth rate 160 BPM. Which . nostril flaring.―T he tissue has hype rtrophied while the baby was in the uterus‖2 4.r doctor.

R ecognize this as normal first period of reactivit y25.The nurse hears a mother telling a friend on the telephon e about umbilical .Start oxygen per nasal cannula at 2 L/min.Cal l the assessm ent data to the physicia n‘s attention b.of the followin gshould the nurse do?a. c.Suctio n the inf ant‘s mo uth and naresd.

―Dail y soap and water cleansin g is best‖b. A .‗ Alcohol helps it dry and kills ger ms‖c.―He c an have a tub bath eac h day‖26.cord care.―A n antibioti c ointment applied daily prevents infection ‖d. Which of the followin g statemen ts by the mother indicates effective teaching ?a.

2 ounces b.4 oun .newborn weighing 3000 grams and feeding every 4 hours needs 120calori es/kg of body weight every 24 hours for proper growth anddevel opment.3 ounces c. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutrition al needs?a.

6 amniotic which of roblems ounces fluid the c.Integ 27.Res piratory proble msb.Ga strointe stinal p umenta ry probl emsd.El iminati on prob lems28. When .The postterm neonate with meconiu mstained needs caredesi gned to especiall y monitor for followin g?a.cesd.

measuri ng a client‘s fundal height.Fro m the symphy sis pubis to the xiphoid process c.From the . From th e xiphoid process to the umbilic usb. which of the followin g techniqu esdenote s the correct method of measure ment used by the nurse?a.

A client with severe preecla mpsia is admitted with of BP 160/110.Fro m the fu ndus to the umbilic us29. Which of the followin g would bemost importa nt to include in the client‘s plan of care?a. and severe pitting edema.symphy sis pubis to the fund usd. . proteinu ria.

Seiz ure pre caution sc. ―When can we have sexualin tercours e again?‖ Which of the followin g would be the nurse‘s bestresp onse?a.Daily weight sb.Righ t lateral position ingd.― Anytim e you both .A postpart um primipar a asks the nurse.St ress red uction3 0.

―After your 6 weeks examin ation. ‖c.‖3 1.‖b. thenurse would select which of .When preparin g to administ er the vitamin K injection to a neonate.want to.― As soon as choo se a contrac eptive method.‖ d.―Wh en the dischar ge has stopped and the incision is healed.

D eltoid muscle b.Whe n performi ng a pelvic examina tion.Anter ior fem oris mu sclec.V astus lateralis muscle d.Glute us maxi mus muscle 32. the nurse observes a red swollen area on the right side of the .the followin g sites as appropri ate for theinject ion?a.

To different iate as a female. the hormon al stimulati on of the embryo thatmust occur involves which of . The nurse would docume ntthis as enlarge ment of which of the followin g?a.vaginal orifice. Skene‘ s gland d.Barth olin‘s gland33 .Cli torisb. Parotid glandc.

Incr ease in materna l estroge n secret ionb. Secretio n of estroge n by the fetal gonad 34.Secr etion of androge n by the fetal gonadd.A client at 8 weeks‘ gestation calls complain ing of slight .the followin g?a.De crease in materna l androge n secretio nc.

Eating a few lowsodium crackers before g etting ou t of bedc. Avoidin g the intake of liquids in the morning hoursd.T aking 1 teaspoon of bicarb onate of soda in an 8ounce glass of water b.E ating six small . Which of the followin g client intervent ions should the nurseque stion?a.nausea in themorni ng hours.

T he nurse understa nds that this indicates which of the followin g?a.meals a day instead of thee large meals35. The nurse documen ts positive ballottem ent in the client‘s prenatal record.F etal kicking felt by the .Passiv e moveme nt of the unen gaged fetusc.Palp able con tractions on the a bdomen b.

Bra xtonHicks signb. Goodell ‘s signd . the nurse explains the .Duri ng a prenatal class. Enlarge ment and softenin g of the uterus36 .McDon ald‘s sig n37.C hadwick ‘s signc.T he nurse documen ts this as which of the followin g?a.clientd.During a pelvic exam the nurse notes a purpleblue tinge of the cervix.

Red uce the risk of fetal distress by increasin g uteropl .rationale for breathing techniqu es during preparati on for labor based on the understa nding thatbreat hing techniqu es are most importan t in achievin g which of thefollo wing?a.E liminate pain and give the expectan t parents somethin g to dob.

the nurse notes that the contracti ons of aprimigr avida client are not strong enough to dilate the cervix. possib ly reduci ng the percepti on of paind. Which of thefollo .acentalp erfusionc .Facilitat e relaxatio n.Eli minate p ain so that less analgesi a and anesthesi a are needed3 8.After 4 hours of active labor.

Increas ing the encourag ement to the patient when pushing begins39 .Admin istering a light sedative to allow the patient to rest for sever alhour c.wing would the nurse anticipat e doing?a.A . Obtainin g an order to begin IV oxytocin infusion b. Preparin g for a cesarean section for failure to progress d.

Whic h of the followin .multigra vida at 38 weeks‘ gestation is admitted with painless.F etal heart rat ec.Mater nal vital signb. Which of thefollo wing assessme nts should be avoided? a. bright redbleedi ng and mild contracti ons every 7 to 10 minutes.Contr action m onitorin gd.Cerv ical dilation 40.

―You will have to ask your physicia n when he returns.‖ b.g would be the nurse‘s most appropri ate response toa client who asks why she must have a cesarean delivery if she has acomplet e placenta previa?a.―You need a cesarean to prevent hemorrh age.― The plac enta is covering most of your cervix.‖c.‖ .

‖41 .Co mpletel y flexedb.With a fetus in the leftanterior . Complet ely exte ndedc.d.Parti ally flexed42 .―The placenta is covering the openi ng of the uteru s and blocking your baby.P artially extende dd.The nurse understa nds that the fetal head is in which of the followin gposition s with a face presentat ion?a.

Above the maternal . Above the maternal umbilicu s and to the right of midlineb .In the lowerright maternal abdomin al quadrant d.In the lowerleft maternal abdomin al quadrant c. the nurse wouldex pect the fetal heart rate would be most audible in which of the followin gareas?a.breech presentat ion.

The amniotic fluid of a client has a greenish tint.Verni x44.The nurse should be particula rly alert . The nurse interprets thisto be the result of which of the followin g?a.Me conium d.umbilicu s and to the left of midline4 3.Lan ugob.H ydramn ioc.A patient is in labor and has just been told she has a breech presentat ion.

P i c a d.Each ova with the .Ophth almia ne onatoru mc .Prola psed umbilica l cord45.Qui ckening b.Tw o ova fer tilized by separ ate sper mb.Shar ing of a common placenta c.for which of the followin g?a. When describin g dizygotic twins to a couple. on which of the followin gwould the nurse base the explanati on?a.

Whic h of the followin g refers to the single cell that reproduc es itself after con ception? a.Troph oblast health care professi onals 47.In beganch the late allengin 1950s. g the consum routine ers and use of .same genotyp ed.Blas tocystc. Zygote d.Chro mosom eb.Shari ng of a common chorion 46.

Prep ared chi ldbirth4 8. postpart um (LDRP) b.Which of the followin g was an outgrow th of this concept ?a.Nurse midwif eryc.A client has a midpelv .analgesi cs and anesthet ics during childbirt h. recover y.Cli nical nurse s pecialis td. delivery .Labo r.

Sacral promon toryc.ic contract ure from a previous pelvic injury due to amotor vehicle accident as a teenager .Sym physis pubisb.Is chial . The nurse is aware that this couldpre vent a fetus from passing through or around which structure duringc hildbirth ?a.

spinesd .Pubic arch49. the nurse understa nds that the underlyi ng mechani sm isdue to variatio ns in which of the followin g phases? a.Mens trual ph . When teaching a group of adolesce nts about variatio ns in the length of themens trual cycle.

whic h of the followin g would the nurse include as being produce d by theLeyd ig cells?a.aseb. Ischemi c phase 50.Secr etory phased.Whe n teaching a group of adolesce nts about male hormon e producti on.Pr oliferati ve phas ec. Follicle stimulat .

Testost eronec. Leutein izing h ormone d. B .ing hor moneb. Regular timely ingestion of oral contrace ptives is necessar y to maintain hormona l levels of the drugs to .Gona dotropi n releasin g horm one ANSWE RS AND RATIO NALE – MATER NAL AND CHILD HEALT H 1.

follicles do not mature.suppress the action of the hypothal amusand anterior pituitary leading to inapprop riate secretion of FSH and LH.Ther efore. regardles s of when the . The estrogen content of the oral site contrace ptive may causethe nausea. ovulation is inhibited. and pregnanc y isprevent ed.

2.pill is taken. are the most effective contrace ptive method or barrier against bacterial and viral sexuallyt ransmitte d . Side effects and druginter actions may occur with oral contrace ptives regardles s of the time thepill is taken. when used correctly and consisten tly. Condom s. C .

Although spermici des kill sperm.infection s. which could . Insertion andremo val of the diaphrag m along with the use of the spermici des maycaus e vaginal irritation s. especiall y intracellu lar organism s such as HIV. they do notprovi de reliable protectio n against the spread of sexually transmitt edinfecti ons.

place the client at risk for infection transmiss ion. The diaphrag m must be fitted individua lly to ensure effective . A . but it does not eliminate bacterial and/or viral microorg anisms that cancause sexually transmitt ed infection s. 3. Male sterilizati on eliminate s spermato zoa from the ejaculate.

In addition. for maximu m effective ness.Bec ause of the changes to the reproduc tive structure s during pregnanc yand followin g delivery. usually at the 6weeks‘ examinat ion followin g childbirt h or after a weight loss of 15 lbs or more. spermici .ness. the diaphrag m must be refitted.

However . Use of a female condom protects the reproduc tivesyste m from the introduct ion of semen or spermici des into the .dal jelly should beplaced in the dome and around the rim. spermici dal jelly shouldno t be inserted into the vagina until involutio n is complete d atapproxi mately 6 weeks.

4. For the couplew ho has determin ed the female‘s fertile period. is safe and effective.vagina andmay be used after childbirt h. C .a voidance of intercour se during this period. using the rhythm method. Oral contrace ptives may be started within thefirst postpartu m week to ensure suppressi on of ovulation .

. especiall yin women with more than one sexual partner. postpartu m infection. because of the increased risk of sexually transmitt ed infection s. An UID should not be used if thewoma n has an active or chronic pelvic infection. An IUD may increase the risk of pelvic inflamm atory disease. endometr ial .

Although there is a slightly higher risk for infertility in women who have never been pregnant.hyperpla sia or carcinom a. Most IUD usersare over the age of 30. Age is nota factor in determin ing the risks associate d with IUD use. or uterine abnormal ities. the IUD is an acceptabl e optionas .

trimeste This . r. IUDs may be insertedi mmediat ely after delivery. the enlargin g uterus places pressure C on . but this is not recomme nded because of theincrea sed risk and rate of expulsio n at this time 5. During theintest the third ines.long as the riskbenefit ratio is discusse d.

Increasi ngfiber in the diet will help fecal matter pass more quickly through theintest inal tract. thus decreasi ng the amount of water that is .coupled with the effect of hormon es on smooth muscler elaxatio n causes decrease d intestina l motility (peristal sis).

absorbe d. stool is softer and easier to pass. As aresult. Enemas could precipita te preterml abor and/or electroly te loss and should be avoided. Laxative s may causepre term labor by stimulati ng peristals is and may interfere with theabsor ption of nutrients .

Liquid in the diet helps provide a semisoli d. . Use for more than 1 week can also lead to laxative depende ncy. soft consiste ncyto the stool.. Eight to ten glasses of fluid per day are essential to maintain hydratio n and promote stool evacuati on.

a total weight gain 25 to 30 pounds is recomm ended: 1. and 27. D .5 pounds by40 weeks.5poun ds in the first 10 weeks. 9 pounds by 30 weeks.6. To ensure adequat e fetal growth and develop ment during the 40 weeksof a pregnan cy. The .

not 1 pound per week. the clientsh ould only gain 1. During the first trimeste r. Aweight gain of ½ pound per week would be 20 .5 pounds in the first 10 weeks.pregnant woman should gain less weight in the first andseco nd trimeste r than in the third.

7. To obtain a date of Septemb . less than the recomm ended amount. To calculat e the EDD by Nagele‘ s rule. changin g the year app ropriatel y.pounds for the totalpre gnancy. add 7 days to the first day of thelast menstru al period and count back 3 months. B .

plus 4months (instead of 3 months) were counted back. 7 days have been subtract ed (instead of added) from thefirst . To obtain the date of Nove mber 27. 7 days have been addedto the last day of the LMP (rather than the first day of the LMP).

To obtain the date of Decemb er 27. 7 dayswer e added to the last day of the LMP (rather than the first day of theLMP ) and Decemb er indicate .day of LMP plus Novemb er indicate s counting back 2 months (instead of 3 months) from January.

The client has been pregnant four times. D.s counting back only 1 month (instead of 3months ) from January. Birth at 38 weeks‘ gestatio n is consider ed full term (T). includin g current pregnan cy(G). while birthfor m 20 . 8.

the uterus rises out of the pelvis and is palpable above the symphy sis pubis. She has two living children (L).weeks to 38 weeks is consider ed preterm (P). At 12 weeks gestatio n. A spontan eousabo rtion occurred at 8 weeks (A). 9. The . B.

Doppler intensifi es the sound of the fetalpuls e rate so it is audible. The uterus has merely risen out of the pelvisint o the abdomin al cavity and is not at the level of the umbilic us. The uterus at 12weeks is just . The fetalhear t rate at this age is not audible with a stethosc ope.

At 12 weeks theFHR would be difficult to ausculta te with a fetoscop e. Althoug h theexter nal electroni c fetal monitor would .above the symphy sis pubis in the abdomin al cavity. notmid way between the umbilic us and the xiphoid process.

Women . 10. Althoug h all of the choices are importa nt in the manage ment of diabet es.project the FHR. the uterus has notrisen to the umbilic us at 12 weeks. diet therapy is the mainsta y of the treatmen t plan and shouldal ways be the priority. A.

thus decreasi ng bloodsu . Exercise . is importa nt for all pregnant women and especiall yfor diabetic women. because it burns up glucose.diagnos ed with gestatio nal diabetes generall y need only diet therapy without medicati on to control their bloodsu gar levels.

not exercise. The standard of care . Howeve r. Howeve r. dietary intake. those with gestatio nal diabetes generall y do not need dailyglu cose monitori ng. is the priority. All pregnant women with diabetes should have periodic monitori ng of serum glucose.gar.

After 20 weeks‘ gestatio n. when there is a rapid weight gain. 11. which may be caused by fluidrete ntion manifest ed by edema.pre eclamps ia should be suspecte d. C. .recomm ends a fasting and 2hour postpran dial blood sugar level every 2 weeks.

Depressi on may cause either anorexia or excessiv efood . Thethre e classic signs of preecla mpsia are hyperten sion.especiall y of the hands and face. andprote inuria. thisis not the priority. edema. Althoug h urine is checked for glucose at each clinic visit.

Weight gain thought to be caused byexces sive food intake would require a 24-hour diet recall. Howeve r. This is not. however .the priority consider ation at this time.intake. leading to excessiv e weight gain or loss.excessi ve intake would not be .

Crampin g and vaginal bleeding coupled with cervical dilation signifies that terminat ion of the pregnan cy is inevitabl e and cannot be prevente d.the primary consider ation for this client atthis time. the nurse would docume nt an . B. 12.Thus.

In a threaten edaborti on. In acomple te abortion all the products of concepti on are expelled . crampin g and vaginal bleeding are present. but there is nocervic al dilation. The sympto ms may subside or progress to abortion .immine nt abortion .

. Thus. usuallyu nilateral. For the client with an ectopic pregnan cy.. is the primary sympto m. pain is the priority.A misseda bortion is early fetal intrauter ine death without expulsio n of the products of concepti on. 13. lower abdomin al pain. B.

the risk is low in ectopicp regnanc y because pathoge nic microor ganisms have not been introduc edfrom external sources. The client may have a limited knowled ge of thepatho logy and treatmen t of the conditio .Althoug h thepoten tial for infectio n is always present.

14. D. A full bladder will interfere with the accurac y of theasses sment by . Before uterine assessm ent is perform ed. it is essential that the womane mpty her bladder. but this is not the priority at this time.n and will most likely experien cegrievi ng.

Vital sign assessm ent is not necessar y unless an abnorma lity inuterin e assessm ent is identifie d.elevatin g the uterus and displaci ng to the side of themidli ne. Uterine assessm ent should not causeac ute pain that requires administ ration of analgesi .

Feeding more frequent ly.a. Ambulat ing the clientis an essential compon ent of postpart um care. 15. about every 2 hours. A. but is not necessar y prior to assessm ent of the uterus. will decrease the infant‘sf rantic. vigorous sucking from .

soften the breast.hunger and will decrease breasten gorgeme nt. Narcotic s administ ered prior to breast feeding are passedth rough the breast milk to the infant. causing excessiv e sleepine ss. . and promote ease of correct latching -onfor feeding.

however .Nipples oreness is not severe enough to warrant narcotic analgesi a. should wear a supporti vebrassi ere with wide cotton straps. This does not. Allpostp artum clients. prevent or reduc e nipple soreness . Soaps are drying . especiall y lactating mothers.

Dry nipple skinpred isposes to cracks and fissures. 16. which can become sore and painful. thready pulse elevated to 100 BPM may indicate impendi .to the skin of the nipples andshou ld not be used on the breasts of lactating mothers. A weak. D.

48F in thefirst 24 hours after birth are related . Thus. Temper atures up to 100.nghemo rrhagic shock. the nurse shouldc heck the amount of lochia present. An increase d pulse is a compen satory mechani sm of the body in response to decrease d fluid volume.

The data indicate a potential impendi .to the dehydrat ing effects of labor andare consider ed normal. it is not the first action that should beimple mented in light of the other data. Althoug h rechecki ng the blood pressure may be acorrect choice of action.

Assessin g the uterus for firmness and position inrelatio n to the umbilic us and midline is importa hemorrh age. but the nurse shouldc heck the extent of vaginal bleeding first. Then it would be appropri ate tocheck the uterus. which may be .

when the lochia is typically pink tobrown ish. 17.a possible cause of the hemorrh age. butespec ially 5 days after delivery. a dark red discharg . Lochia rubra. D. Any bright red vaginal discharg e would be consider ed abnorma l.

which occurs after the first 24 hours followin gdeliver y and is generall y caused by retained placenta l fragmen ts or bleedi ng . is present for 2 to 3 daysafte r delivery.e. Bright red vaginal bleeding at this time suggests latepost partum hemorrh age.

leukocyt es and decidua.ery throcyes .disorder s. Lochia rubra is the normal dark red discharg eoccurri ng in the first 2 to 3 days after delivery. Lochia serosa is a pink to brownis hserosan guineou s discharg e occurrin g from 3 to 10 . containi ng epithelia l cells.

andmicr oorganis ms. cervical mucus. . decidua. erythroc ytes.days after delivery thatcont ains decidua. Lochia alba is an almost colorles s to yellowis h discharg eoccurri ng from 10 days to 3 weeks after delivery and containi ngleuko cytes. leukocyt es.

dark brown in appeara nce. cervical mucus. 18. fat. The data suggests an infectio n of the endomet rial lining of the uterus. choleste rolcrysta ls. providin . A. and bacteria.T he lochia may be decrease d or copious. andfoul smelling .epithelia l cells.

usually 101ºF. may be present with breast engorge ment.g further evidenc e of a possible infectio n. Localize dinfecti .transie nt fever. Typicall y. All theclient ‘s data indicate a uterine problem . not a breast problem .Sy mptoms of mastitis include influenz a-like manifest ations.

The client data do not include dysuria. or urgency. sympto ms of urinary tractinfe ctions. frequenc y. which would necessit ate assessin . and uterine involuti on would not be affected.on of an episioto my or Csection incision rarely causes systemic sympto ms.

Because of early postpart um discharg e and limited time for teaching . C.g the client‘s urine. 19.the nurse‘s priority is to facilitate the safe and effective care of the clientan d newborn . Althoug h promoti ng comfort and restorati on of .

20. and teaching about family planning are importa nt in postpart um/new born nursing care.e xploring the family‘s emotion al status. they are not the priorityf ocus in the limited time presente d by early postpartum discharg C. .

Heat loss by radiatio n occurs when the infant‘s crib is placed too near col d walls or window s. Body heat is lost through evaporat ion during bathing. Thus placing the newborn ‘s crib close to theviewi ng window would be least effective . Placing the .

A knit cap prevents heat loss from the head a large head. Coverin g the scale witha warmed blanket prior to weighin g prevents heat loss through conducti on. a large .infant under the radiant warmer after bathing will assist the infant to be rewarme d.

21.bodysur face area of the newborn ‘s body. B. A fracture d clavicle would prevent the normal Moro response of sym metrical sequenti al extensio n and abductio n of the arms followe d byflexio n and adductio n. In talipes equinov .

and in plantar flexion. with the heel elevated . The feet are notinvol ved with the Moro reflex.arus (clubfoo t) the foot is turnedm edially. Absence of the Moror reflex is the most significa ntsingle indicato r of . Hypothy roiddis m has no effect on theprimi tive reflexes.

theprop hylactic dose is often .Altho ugh the infant has been given vitamin K to facilitate clotting. B.central nervous system status. but it is not a sign of increa sed intracra nial pressure . 22. Hemorr hage is a potential risk followin g any surgical procedu re.

Althoug hinfecti on is a possibili ty. The primary discomf ort of circumci sion occurs duringth e surgical procedu re. not afterwar d. Althoug h feedings .not sufficien t to prevent bleeding . signs will not appear within 4 hours after thesurgi cal procedu re.

The presence of excessiv e estrogen and progeste rone in the maternal -fetal blood followe d by prompt withdra wal at birth precipita tes breasten .are withheld prior to the circumci sion. 23. B. the chances of dehydrat ion are minimal .

Newbor ns do not have breast maligna ncy.gorgeme nt. Thisrepl y by the nurse would cause the mother . which will spontan eously resolve in 4 to 5 days after birth.Th e trauma of the birth process does not cause inflamm ation of thenewb orn‘s breast tissue.

Breasttis sue does not hypertro phy in the fetus or newborn have undue anxiety. The first 15 minutes to 1 hour after birth is the first period of reactivit yinvolvi ng respirato ry and circulato ry adaptati on to extraute rine life. Thedata . 24. D.

The infant‘sa ssessme nt data reflect normal adaptati on.given reflect the normal changes during this time period. The data do not indicate theprese nce of choking. the physicia n does notneed to be notified and oxygen is not needed. gagging or coughin . Thus.

g. Suctioni ng is not necessar y 25. B. which are signs of excessiv esecreti ons. The cord should bekept dry until it falls off and the . Applicat ion of 70% isopropy l alcohol to the cord minimiz esmicro organis ms (germici dal) and promote s drying.

B. Antibiot ic ointmen tshould only be used to treat an infectio n. 26. not as a prophyl axis. Infantss hould not be submerg ed in a tub of water until the cord falls off and thestum p has complet ely healed. To determi ne the .stump has healed.

do the followin gmathe matical calculati on. 3 kg x 120 cal/kg per day = 360 calories/ dayfeedi ng q 4 hours = 6 feedings per day = 60 calories per feeding: 60calori es per feeding.amount of formula needed. 60 calori es per feeding with formula 20 cal/oz = 3ounces .

4 or 6 ounces areincor rect.per feeding. Intrauter ine anoxia may cause relaxatio n of the anal sphincte r andempt ying of meconiu m into the amniotic fluid. A. 2. Based on the calculati on. 27. At birth some of themeco nium fluid may be .

aspirate d. The postterm . The infant is not at increase d risk for gastr ointestin al problem s. Even though the skin is stained with meconiu m. causing mechani cal obstructi on or chemi cal pneumo is noninfec tious (sterile) and nonirrita ting.

paper measuri ng tape.pla cing the zero point on the superior border of the symphy sis pubis andstret ching . 28. C.meconiu mstained infant is not at addition al risk for bowel or urinary problem s. The nurse should use a nonelast ic. flexible.

B. The xiphoid and umbilic us are not appropri ate landmar ks to usewhen measuri ng the height of the fundus (McDon ald‘s measure ment).the tape across the abdome n at the midline to the top of thefund us. Women hospitali zed with severe preecla . 29.

mpsia need decrease d CNSsti mulatio n to prevent a seizure. Because of edema. Preclam psia causes vasospa smand therefor e can . dailywei ght is importa nt but not the priority. Seizure precauti ons providee nvironm ental safety should a seizure occur.

The client should beplace d on her left side to maximiz e blood flow. andpro mote diuresis. . reduce blood pressure . Interven tions to reduce stress and anxiety are veryimp ortant to facilitate coping and a sense of control.reduce uteroplacenta l perfusio n.

Ris k of hemorrh age and infectio n are minimal 3 weeks after a normalv aginal delivery. 30. C.but seizurep recautio ns are the priority. Cessatio n of the lochial discharg e signifies healing of the endomet rium. Telling the client anytime is inappro .

Choice of a contrace ptive method is importa nt. but not thespeci fic criteria for safe resumpti on of sexual activity. Cultural ly. the 6weeks‘ examina .priate because thisresp onse does not provide the client with the specific informat ion she isreques ting.

tion has been used as the time frame for resumin g sexualac

tivity, but it may be resumed earlier. 31. C . The middle

third of the vastus lateralis is the preferre d injection site

for vita min K administ ration because it is free of blood vessels and

nervesa nd is large enough to absorb the medicati on. The

deltoid muscle of anewbor n is not large enough for a newborn

IM injection . Injectio ns into thismus cle in a small child

might cause damage to the radial nerve. The
anterior femoris

muscle is the next safest muscle to use in a newborn butis not the safest.

Because of the proximit y of the sciatic nerve, the gluteusm aximus muscle

should not be until the child has been walking 2 years. 32. D

. Bartholin ‘s glands are the glands on either side of the vaginal orifice.T

he clitoris is female erectile tissue found in the perineal area above

theurethr a. The parotid glands are open into the mouth. Skene‘s glands openinto

the posterior wall of the female urinary meatus. 33. D

. The fetal gonad must secrete estrogen for the embryo to differenti

ateas a female. An increase in maternal estrogen secretion does not effectdiff

erentiatio n of the embryo, and maternal estrogen secretion occurs inevery pregnanc

y. Maternal androgen secretion remains the same asbefore pregnanc y and does not

effect differenti ation. Secretion of andro gen by the fetal gonad would produce

a male fetus. 34. A . Using bicarbon ate would increase the

amount of sodium ingested, which can cause complica tions. Eating

lowsodium crackers would beapprop riate. Since liquids can increase

nausea avoiding them in themorni ng hours when nausea is usually the strongest

is appropri ate. Eatingsix small meals a day would keep the stomach

full, which often decrease nausea. 35. B . Ballotte ment

indicates passive moveme nt of the unengag ed fetus.Bal lottement is not a contracti

on. Fetal kicking felt by the client represent squicken ing. Enlarge ment and softening

of the uterus is known asPiskac ek‘s sign. 36. B . Chadwic

k‘s sign refers to the purpleblue tinge of the cervix. Braxton Hicks

contracti ons are painless contracti ons beginnin g around the 4

month. Goodell‘ s sign indicates softening of the cervix. Flexibilit y of theuterus

against the cervix is known as McDonal d‘s sign. 37. C

. Breathin g techniqu es can raise the pain threshold and reduce

theperce ption of pain. They also promote relaxatio n. Breathin g

techniqu es donot eliminate pain, but they can reduce it. Positioni ng, not breathing ,increase

s uteroplac ental perfusion . 38. A . The client‘s labor is

hypotoni c. The nurse should call the physical andobtai n an order for an

infusion of oxytocin, which will assist the uterus tocontact more forcefull

y in an attempt to dilate the cervix. Administ eringligh t sedative would be done for

hyperton ic uterine contracti ons. Preparin gfor cesarean section is unnecess ary at

this time. Oxytocin would increaset he uterine contracti ons and hopefull y

progress labor before a cesarean would be necessar y. It is too early to anticipat

e client pushing withcont ractions. 39. D . The signs indicate placenta

previa and vaginal exam to determin ecervical dilation would not be done

because it could cause hemorrh age.Asse ssing maternal vital signs can help

determin e maternal physiolo gicstatus. Fetal heart rate is importan t to

assess fetal wellbeing and shouldbe done. Monitori ng the contracti

ons will help evaluate the progress of labor. 40.


.A complet e placenta previa occurs when the placenta

covers theopeni ng of the uterus, thus blocking the passage

way for the baby. Thisresp onse explains what a complet e previa

is and the reason the babycan not come out except

by cesarean delivery. Telling the client to ask thephysi cian is a

poor response and would increase the patient‘s anxiety. Althoug

ha cesarean would help to prevent hemorrh age, the stateme ntdoes

not explain why the hemorrh age could occur. With a complet

eprevia, the placenta is covering all the cervix, not just

most of it. 41. B . With a face presenta tion, the head is

complet ely extende d. With avertex presenta tion, the head is complet

ely or partially flexed. With a brow(fo rehead) presenta tion, the head

would be partially extende d. 42. D . With this

presenta tion, the fetal upper torso and back face the left

upper m aternal abdomin al wall. The fetal heart rate would

Lanugo is thesoft. most audiblea bove the maternal umbilic us and to the left of the middle. C. downy hair on the shoulder s and . The greenish tint is due to the presence of meconiu m. The other po sitions would be incorrec t.

D.back of the fetus. In a breech position. Vernix is the white. prolapse of the umbilica . cheesy substanc ecoverin g the fetus. because of the space between the presenti ng partand the cervix. Hydram niosrepr esents excessiv e amniotic fluid. 44.

Pica refers tothe oral intake of nonfood substanc es. Ophthal mia neonator umusual ly results from maternal gonorrh ea and is conjunct ivitis.l cord is common . 45. A. Dizygoti c . Quicken ing isthe woman‘ s first percepti on of fetal moveme nt.

C. same genotyp e. Monozy gotic (identica l) twins involve a common placenta .(fraterna l) twins involve two ova fertilize d by separate sperm. The zygote is the single cell that reprodu ces itself after concepti on. 46. Thechro mosome is the .and common chorion.

Blastocy st and trophobl ast are later terms for the embryoa fter zygote. 47. D.material that makes up the cell and is gained fromeac h parent. Prepare d childbirt h was the direct result of the 1950‘s challeng ing of therouti ne use of .

The LDRP wasa much later concept and was not a direct result of the challeng ing of routin e use of analgesi cs and anesthet ics during childbirt h. Roles for nurs e midwive s and clinical nurse specialis ts did .analgesi c and anesthet ics during childbirt h.

not develop from thischall enge. 48. C. The ischial spines are located in the midpelvic region and could benarro wed due to the previous pelvic injury. sacralpr omontor y. The symphy sis pubis. and pubic arch are not part of the .

Testoste rone is produce d by the . 50. secretor y and ischemi c phases donot contribu te to this variatio n. 49. B . Variatio ns in the length of the menstru al cycle are due to variatio ns inthe prolifera tive phase. The menstru al. B.midpelvis.

The hypothal amus is responsi blefor releasin g gonadot ropinreleasin g hormon e MEDIC AL SURGI .Leyding cells in the seminife roustubu les. Folliclestimulati ng hormon e and leuteinzi ng hormon e are released by the anterior pituitary gland.

the nursesho uld expect the use of:a.CAL NURSI NG 1.Ster oidsd. Halfway through the . Marco who was diagnose d with brain tumor was schedule d for cranioto my.Diu reticsb.A nticonv ulsants 2. Inpreven ting the develop ment of cerebral edema after surgery. Antihyp ertensiv ec.

Assess the pain further c . Nurse Maureen knows that the positive diagnosis for HIV i . the female client complain s of lumba r pain. Increase the flow of normal salineb.administr ation of blood.O btain vital signs.Notify the blood bankd. 3. After stopping the infusion Nurse Hazel should:a.

A history o f high risk sexual behavior s.Identi fication of an associat ed opportu nistic infection d. Nurse Maureen is aware that a client who has .Eviden ce of extreme weight loss and high fever 4.nfection is madebas ed on which of the followin g:a.Posit ive ELIS A and western blot test sc.b.

been diagnose d with chronicre nal failure recogniz es an adequate amount of highbiologicvalue proteinw hen the food the client selected from the menu was:a.R aw carrots b.Apple juicec. Cottage cheese 5. Kenneth who has diagnose d with uremic syndrom e has the potential todevelo . Whole wheat breadd.

Which among the followin g complica tions should thenurse anticipat es:a.An elevated hematoc rit levelc. A client is admitted to the hospital with benign prostatic hyperpla sia.p complica tions.Flap ping han d tremor sb.H ypotens iond. the nursemo st relevant assessme .Hy pokale mia 6.

After 24 hrs of surgery. the client‘ssc rotum was edemato us and painful. The nurse should:a.Perin eal ede mad.Ur ethral discharg e 7. Assist th e client with .Fla nk pain radiating in the groinb. A client has undergon e with penile implant.nt would be:a.D istention of the lowe r abdome nc.

sitz bath b. Nurse hazel receives emergen cy laborator y results for a client with chest painand immediat ely informs the physicia n.Ele vate the scrotum using a soft support d. An increased myoglob .Prepar e for a possible incision and drainage . 8.Apply war soaks in the scrot umc.

Nurse Maureen would expect the a client with mitral stenosis wouldde monstrat e symptom s associate d with congesti on in the:a.Hyper tension d. .Canc er 9.My ocardial damage c.Ri ght atri umb.Su perior vena cavac .Liv er disea levelsug gests which of the followin g?a.

Defici ent fluid volume d. Nurse Hazel teaches the client with angina about common expected sideeffec ts of nitroglyc erin .Pain 11.Pulmo nary 10. The nurse priority nursingdi agnosis would be:a.Aortad .Impa ired skin integrity c.Inef fective h ealth ma intenanc eb. A client has been diagnose d with hyperten sion.

hea dached.including :a.stoma ch cram psc. Which of the followin g is a risk factor for the develop ment of atheroscl erosis and PVD?a.Hig .high blood pressure b. shortnes s of breath 12. The followin g are lipid abnormal ities. High levels of low density lipid (LDL) choleste rolb.

Pot ential wound infectio nb.Lo w levels of LDL choleste rol.Lo w conce ntration triglycer idesd. Which of the followin g represent sa significa nt risk immediat ely after surgeryf or repair of aortic aneurys m?a.h levels of high density lipid (HDL) choleste rolc.Poten tial ineff ective co pingc.Po tential electrol . 13.

Karen has been diagnose d with aplastic anemia.Potenti al alteratio n in renal perfusio n 14. The . Nurse Josie should instruct the client to eat which of the followin g foods toobtain the best supply of Vitamin B12?a. Grains d.vege tablesc.Brocc oli 15.yte balance d.d airy product sb.

nurse monitors for chang es in which of the followin g physiolo gic functions tendenc splenect ? iesd.Per ipheral sensatio nc.Blee ding ake and out put 16. the nurse in .Int omy. a. Lydia is schedule d for elective Before the clients goes tosurger y.Bowe l functi onb.

20 to 3 0 years c.sig ned con sentb. . name b andd.4 to 12 years.v ital signsc.e mpty bladder age range in acquirin g acute lymphoc ytic 17.b .40 to 50 yearsd. leukemi What is a the peak (ALL)? a.charge final assessm ent would be:a.

gastric . effects of radia tionb. Marie with acute lymphoc ytic leukemi a suffers from nausea and headach e.These clinical manifest ations may indicate all of the followin g excepta.60 60 7 0 years 18.menin geal irr itationd .c hemoth erapy side effectsc .

A client has been diagnos ed with Dissemi nated Intravas cular Coagula tion(DI C).Tr eating the underly ing caused. Which of the followin g is contrain dicated with the client?a. Admini stering Heparin b. Replaci .Admi nisterin g Couma dinc.distensi on 19.

Which of the followin g findings is the best indicatio n that fluid replace ment for the client with hypovol emic shock is adequat e?a.Uri ne output g reater th an 30ml /hr b.Re spirator y rate o f 21 breaths/ minutec .ng deplete d blood p roducts 20.

Systolic blood pressure greater than 110 mmhg 21. Which of the followin g signs and sympto ms would Nurse Mauree n include inteachi ng plan as an early manifest ation of laryngea l cancer? a.Diastol ic blood pressure greater than 90 mmhgd..Stom .

Pro motes th e removal of antib odies that imp . Karina a client with myasthe nia gravis is to receive immuno suppress ivethera py.atitisb.D ysphag ia 22.H oarsen essd. Airway obstruc tionc. The nurse understa nds that this therapy is effective because it:a.

c.Stimul ates the prod uction of acety lcholine at the neur omuscul ar junct ion.Decre ases the producti on of autoanti bodies that attack theacety lcholine receptor s.d. .Inhi bits the breakdo wn of acetylch oline at the neur omuscul ar juncti on.air the transmis sion of i mpulses b.

A female client is receivin g IV Mannito l. An assessm ent specific to safeadm inistratio n of the said drug is:a.Vit al signs q4hb.Level of conscio usness q4h 24. Weighi ng dailyc. Patricia a 20 year old college .23. Urine output hourlyd .

Accu rate dos e deliver yb. The nurse explains that the advanta ges of these deviceso ver syringes includes :a.Shor ter injectio .student with diabetes mellitus requests addition al informat ion about the advanta ges of using a pen like insulind elivery devices.

A male client‘s left tibia is fractures in an automob ile accident .the nurse in . 25. To assess for damage to major blood vessels from the fracture tibia.Use of smaller gauge needle. and a cast isapplie d. Lower cost with reusable insulin cartridg esd.n timec.

Pr olonged reperfus ion of the toes after blanchi ngd. the male client should:a .S welling of the left thig hb.Inc reased blood pressur e 26.Incre ased skin tempera ture of the footc. After a long leg cast is removed .charge should monitor the client for:a.

Put leg through full range of moti on twice dailyc..Cleans e the leg by scrubbi ng with a brisk motionb . 27. While performi ng a physical assessm .Elev ate the leg when sitting for long periods of time. Report any discomf ort or stiffnes s to the physicia nd.

Nurse Katrina would recogniz e that the demonst ration of crutch walking withtrip . NurseVi vian should assess for addition al tophi (urate deposits ) onthe:a.A bdome n 28.Fa c e d. Buttoc ksb . E a rsc.ent of a male client with gout of thegreat toe.

Axil lary reg ionsd. Mang Jose with rheumat oid arthritis states. ―the only .Pa lms of the hands and axillary regions b.F eet. which are set apart 29.od gait was understo od when the client places weight on the:a.Palm s of the han dc.

the nurse incharge with Mang Jose should encoura ge:a. During the convales cent stage.Conti nued immobi lity until pain subside .time I am without pain iswhen I lie in bed perfectl y still‖.Act ive joint fle xion an d extens ion b.

F lexion exercise s three times daily 30.Observ e the client‘s bowel movem ent and voiding patterns e of moti on exer cises twice dailyd. the nurse should:a . A male client has undergo ne spinal surgery.Logroll the client to prone position .

Marina with acute renal failure moves into the diuretic phase after one weekof therapy.Enc ourage client to drink plenty o f fluids 31. During this phase the client must be assessed for signs of devel oping:a.c.Asses s the client‘s feet for sensatio n and circulati ond. .

metab olic acidosi sd. Which of the followin g tests different iates mucus fromcer ebrospin al fluid .Hypov olemia b.renal failurec . Nurse Judith obtains a specime n of clear nasal drainage from a client with ahead injury.hype rkalemi a 32.

―What caused me to have a seizure? Which of the followin g would the nurse . A 22 year old client suffered from his first tonicclonic seizure.(CSF)?a .Protei nb.Spe cific gr avityc. Uponaw akening the client asks the nurse. Glucos ed.Mic roorga nism 33.

What is the priority nursing assessm ent in the first 24 hours after admissi on of the client with thrombo . Electrol yte imb alanceb .Co ngenita l defect 34.include in the primary cause of tonicclo nic seizures in adults more the 20 years?a.Head t raumac .Epilep syd.

Nurse Linda is preparin ga client with multiple sclerosis for discharg e from thehospi tal to home. Which of the followin g instructi on is .chol esterol levelc.tic CVA?a.Bo wel sou nds 35. Echoca rdiogra md. Pupil size and papillar y respons eb.

c.―P ractice u sing the mechani cal aids that you will need when futuredi sabilities arise‖.―Yo u will need to accept .d.―Kee p active.most appropri ate?a. use stress re duction strategie s. ―Follow good health habits to chang e the course of the disease‖ .b. and avoi d fatigu e.

Cy anosis b.the nece ssity for a quiet and inactive lifestyle ‖. The nurse is aware the early indicato r of hypoxia in the unconsc ious client is:a. A client is experien cing spinal .Incre ased respirat ions c.Hyper tension d.Restle ssness 37. 36.

Spastic d. . Which of the followin g stage the carcinog en is irreversi ble?a. Regress ion stag ed.shock.Prom otion st age 39.A tonicc.I nitiation stagec. Nurse Myrna should expect the function of the bladder to be which of the followin g?a.Unco ntrolled 38.Pr ogressio n stageb.Nor malb.

Which of the client‘sa ction could aggravat e the cause of flare ups?a. Causing factorsd . A 65 year old female is experien cing flare up of pruritus.Intensi ty 40. which is themost significa nt?a. C a u s e c.Among the followin g compone nts thorough pain assessme nt.Eff ectb .Sl eeping in cool .

U sing clothes made from 10 0% cottond. Increasi ng fluid intake 41.A client with hig h bloodb. A client with bo wel obstructi onc.A .and humidifi ed environ mentb.D aily baths with fragrant soapc. Atropine sulfate (Atropin e) is contraind icated in all but one of the followin gclient?a .

Nurse Jon assesses vital signs on . 49-yearold clientc.T. Among the followin g clients.client with glaucom ad. 15-yearold client 43.I 42. 33-yearold clientd.67year-old clientb. which among them is high risk for potential hazards from the surgical experien ce?a.A client with U.

a client undergon e epidural anesthesi a.Bla dder distensi onc. Headac heb.Diz zinessd.Which of the followin g would the nurse assess next?a. Ability to move legs 44. Nurse Katrina should anticipat e that all of the followin g drugs may be used inthe attempt to control the symptom s of .

Antiem etics b.Increa sed blood pressure d.Dama ge to .Diure ticsc. Acute respirato ry distress syndrom e (ARDS) c.A ntihista minesd.Meniere' s disease except:a.I ncreased cardiac outputb. Which of the followin g complica tions associate d with tracheost omy tube?a. Glucoco rticoids 45.

laryngea l nerves 46. Total volume of intravas cular plasmac. Permeab ility of capillar y wallsd.Tot al volume of circulati ng whol e bloodb.P ermeabil ity of ki . Nurse Faith should recogniz e that fluid shift in an client with burn injury resultsfro m increase in the:a.

Nurse Anna is aware that early adaptatio . elder ab use 48. An 83year-old woman has several ecchymo tic areas on her right arm. Thebruis es are probably caused by:a.dney tub ules creased blood su pply to the skinc.incr eased capillary fragility and permeab ilityb.sel f inflicted injuryd.

flan k painc.6 to 12 .n of client with renal carcinom a is:a.Nau sea and vomitin gb. weight termitte nt hemat uria 49. Nurse Brian‘s accurate reply would be:a. A male client with tuberculo sis asks Nurse Brian how long the chemoth erapymu st be continue d.1 to 3 weeks b.

3 years an d more 50. Monitor for signs of infectio nc.Keep t rachea fr ee of sec retionsb.Provi de emotion al supportd .months c.Promot e means of comm unicatio n ANSWE RS AND RATIO NALE – .3 to 5 mont hsd. The immediat e nursing priority wouldbe: a. A client has undergon e laryngect omy.

whichde creases the develop ment of edema. 2. Glucocor ticoids (steroids) are used for their antiinflamm atory action. and then normal saline should beinfuse d to keep the line patent and .MEDIC AL SURGI CAL NURSI NG 1. The blood must be stopped at once. A . C .

maintain blood volume. 3. D . 9 g of fat. 27 g of protei n. 4. One cup of cottage cheese contains approxi mately 225 calories. These tests confirm the presence of HIVa ntibodies that occur in responset o the presence of the human immuno deficienc y virus (HIV). B . 30 mg cholester .

resultingi n flapping hand tremors. B . 6. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life. 5.ol. A . and 6 g of carbohyd rate. Elevatio n of uremic waste products causes irritation of the nerves. This indicates that the bladder is .

9. B . Elevatio n increases lymphati c drainage. 7. 8. therefore palpable.distende d with urine. reducing edema and pain. When mitral stenosis i . C . Detectio n of myoglob in is a diagnosti c tool to determin e whether myocardi al damage has occurred. D .

the left atrium has diffic ulty emptying itsconten ts into the left ventricle because there is no valve to prevent back wardflo w into the pulmona ry vein.s present. the pulmona ry circulatio n is under pressure. 10. A . Managin g hyperten sion is the priority for the client with .

11. Because of its widespre ad vasodilat ing effects. It is the asympto matic nature of hyperten sion thatmake s it so difficult to treat.o r impaired skin integrity.Clie nts with hyperten sion frequentl y do not experien ce pain. C .hyperten sion. nitroglyc erin oftenpro duces side . deficient volume.

D .effects such as headache . hypotens ion and dizziness . 13. An increased in LDL cholester ol concentr ation has been documen ted atrisk factor for the develop ment of atheroscl erosis.A.12. LDL cholester ol is notbroke n down into the liver but is deposite d into the wall of the blood vessels.

. or prolonge d aortic crossclamping duringth e surgery. There is a potential alteration in renal perfusion manifest ed by decrease durine output. A . prolonge d hypotens ion. The altered renal perfusion may be related to renal arteryem bolism. 14. Good source of vitamin B12 are dairy products .

whiteblo od cells. The client is at risk for bruising and bleedingt endencie s. 16. Aplastic anemia decrease s the bone marrow producti on of RBC‘s.and meats. and platelets. 15. C . B. An elective procedur e is schedule d in advance so that all preparati .

17. The peak incidenc e of Acute Lympho cytic Leukemi a (ALL) is 4 years of age. A . It is uncomm on after .ons canbe complete d ahead of time. The vital signs are the final check that must becompl eted before the client leaves the room so that continuit y of care andasses sment is provided for.

D . and clients experien ce headache sand vomiting from meninge al irritation.15 years of age. 19. Itdoes invade the central nervous system. Dissemin ated Intravasc ular Coagulat ion (DIC) . Acute Lympho cytic Leukemi a (ALL) does not cause gastric distentio n. 18. B .

Early warning . A . C . 20. Urine output provides the most sensitive indicatio n of the client‘s responset o therapy for hypovole mic shock.has not been found torespon d to oral anticoag ulants such as Coumadi n. Urine output should be consisten tly greater th an 30 to 35 mL/hr. 21.

Steroids decrease the body‘s immune response thus decreasin g theprodu ction of antibodie s that attack the acetylch . Hoarsene ss lasting 2 weeks should be evaluate d because it is oneof the most common warning signs.signs of laryngeal cancer can vary dependin g on tumor lo cation. C . 22.

C .oline receptors at theneuro muscular junction 23. A . These devices . 24. The osmotic diuretic mannitol is contraind icated in the presence of inadeq uate renal function or heart failure because it increases theintrav ascular volume that must be filtered and excreted by the kidney.

25. this would indicate .are more accurate because they are easily to used andhave improve d adherenc e in insulin regimens by young people because themedic ation can be administ ered discreetl y. C . Damage to blood vessels may decrease the circulato ry perfusion of thetoes.

B. 27. it tends to precipitat e and form deposits atvarious sites where blood flow is least active.the lack of blood supply to the extremit y. D. including cartilagin ous tissuesuc . 26. Elevatio n will help control the edema that usually occurs. Uric acid has a low solubility .

alternatin g extensio n. 28. B .h as the ears. . 29. A . The palms should bear the client‘s weight to avoid damage to the nerves inthe axilla. C.mobiliz e exudates in the joints relieves stiffness and pain. 30. and adductio n. abductio n. Active exercises . flexion.

Alteratio n in sensation and circulatio n indicates damage to the spinal cord. 31. hypovole mia may occur and fluids should .if these occurs notify physicia n immediat ely. A . In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily.

Trauma is one of the primary cause of brain damage and . C . 33. 32. A CSF normally contains glucose. B . Anexami nation for glucose content is done to determin e whether a body fluid isa mucus or a CSF. The constitue nts of CSF are similar to those of blood plasma.bereplac ed.

35. 34. The nurse . It is crucial to monitor the pupil size and papillary response to indicatec hanges around the cranial nerves. C . A . and vascular disease.seizure activity inadults. Other common causes of seizure activity in adults include neoplas ms.withd rawal from drugs and alcohol.

most positive approach is to encourag e the client with multiples clerosis to stay active. 36. The . Restless ness is an early indicato r of hypoxia. D . use stress reduction techniqu es and avoid fatiguebe cause it is importan t to support the immune system while remainin g active.

Progress . 37. B . the bladder becomes complet ely atonic and will continue to fill unless the client is catheteri zed.nurse should suspecth ypoxia in unconsc ious client who suddenl y becomes restless. In spinal shock. A . 38.

ion stage is the change of tumor from the preneopl astic state or low degree of maligna ncy to a fast growing tumor that cannot be reversed . 39. D . Intensity is the major indicativ e of severity of pain and it is importa nt for theevalu .

ation of the treatmen t. . The use of fragrant soap is very drying to skin hence causing the pruritus. 41. 40. B. Atropin e sulfate is contrain dicated with glaucom a patients because itincreas es intraocu lar pressure . C. 42.

A . A 67 year old client is greater risk because the older adult client is morelik ely to have a lesseffective immune system. 43. The last area to return sensatio n is in the perineal area. and the nurse incharge should monitor the client for distende . B .

45. . 46. In burn. C . D . Glucoco rticoids play no significa nt role in disease treatmen t.infectio n and laryngea l nerve damage.d bladder. D . Tracheo stomy tube has several potential complic ations includin g bleeding . 44.

47.the capillari es and small vessels dilate. Aging process involves increase . The substanc e causes the capillary walls to become more permeab le and significa nt quantitie s of fluid are lost. and cell damage cause therelea se of a histamin e-like substanc e. A .

. Older ad ults have a decrease d amount of subcuta neous fat and cause an increase dinciden ce of bruise like lesions caused by collectio n of extravas cular blood inloosel y structure d dermis.d capillary fragility and permeab ility. 48.

Intermitt ent pain is the classic sign of renal carcino ma. B. Usually a .D . 49. Tubercl e bacillus is a drug resistant organis m and takes a long time to beeradic ated. It is primaril y due tocapilla ry erosion by the cancero us growth.

combina tion of three drugs is used for minimu m of 6months and at least six months beyond culture conversi on. therefor e removal of secretio ns isnecess ary. PSYCH IATRIC NURSI NG . Patent airway is the most priority. 50. A.

Avers ion Ther apy2.Nu rse Hazel is caring for a . Total ab stinence d.A.Psy chother apyb.1.Al coholics anonym ous (A. Nurse Trish should tell the client that the only effectivet reatment for alcoholis m is:a.)c.Marco approach ed Nurse Trish asking fo r advice on how to deal with hisalcoh ol addiction .

Whe n accompa nying the client to the restroom.Loose associat ionsd.Nur se Monet is caring for a female client who has suici dal tende ncy.N eologis ms3.De lusions c.male client who exp erience false sen soryperc eptions with no basis in reality.Hal lucinati onsb. This perceptio n is known as:a. Nurse Monet .

Give h er privacy b. Nurse Maureen is developi ng a plan of care for a female client withanor exia nervosa.should… a.Ob serve her 4.P rovide .Allow her to urinatec . Which action should the nurse include in the plan?a.Open the window and allow her to get some fresh air d.

Restrict visits with the family5. The mos t appropri ate nursingi nterventi on should include? a. Set-up a strict eating plan for the clientc.privacy during mealsb.Turnin g on the televisio nb. A client is experien cing anxiety attack.Leav ing the .E ncourag e client to exercise to reduce anxietyd .

Resp .client alonec. A female cl ient is admitted with a diagnosi s of delusi ons of GRAND EUR.Ask the client to play with other clients6.Thi s diagnosis reflects a belief that one is:a.Bei ng Kille db.S taying with the client and speaking in short sentence sd.High ly famous and importa ntc.

Which behavior is not likely to be evidence of ineffecti ve individua l coping?a .Recurre nt selfdestructi ve behavior b. Connect ed to client unrelate d to onesel f 7.onsible f or evil worldd.A 20 year old client wa s diagnose d with depende nt person ality disorder.Avoid ing relat ionshipc .

. Whic hsigns would this client exhibit during social situation ? a. A male clie nt is diagnose d with schizoty pal personali ty disord er.I ndepend .Paran oid thought sb.Emot ional affectc.Showin g interest in solitary activitie sd.Inabil ity to make choices and decision without advise8.

Av oid shoppin g plenty of grocerie s10.Eat only thr ee meals a dayd. The mostappr opriate initial goal for a client diagnose d with bulimia is?a.Enc ourage to avoid foodsb. .Agg ressive behavior 9.ence ne edd.Nurse Claire is caring for a client diagnose d with bulimia.I dentify a nxiety c ausing si tuations c.

Generat es new levels of aware nessb.Has maximu m ability to solve problem s and learn new skillsd.H er perce ption are based on reality11 .As sumes re sponsibi lity for her actio nsc.A . Which behavior bythe client indicates adult cognitive develop ment?a.Nurse Tony was caring for a 41 year old female client.

Na usea and vomitin gc.Dizz iness d. Seizures 12.neuromu scular blocking agent is administ ered to a client before ECTther apy. The Nurse should carefully observe the client for?a.Re spirator y difficult iesb.A 75 year old client is admitted to the hospital with the diagnosis of demen tia of the Alzheim er‘s type and .

Neglect of personal hygiene 13. the nurse priority nursingin terventio n for a newly .depressio n.Ap athetic response to the environ mentb.Shall ow of la bile effectd. The symptom that isunrelat ed to depressio n would be?a.―I don‘t kn ow‖ answer t o question sc.Nurse Trish is working in a mental health facility.

admitted client with bulimia nervosa would be to?a.Tea ch client to measure I& Ob.Invol ve client in planni ng daily mealc.Car .O bserve client du ring mealsd. Monitor client continuo usly14.N urse Patricia is aware that the major health complica tion associate d withintra ctable anorexia nervosa would be?a.

diac dysrhyth mias resulting to cardiac arrestb. Endocri ne imbalan ce causing cold amenorr head.Inc reasing stimulat .De creased metaboli sm causing cold intoleran ce15. Glucose intoleran ce resulti ng in pro tracted hypogly cemiac.Nu rse Anna can minimiz e agitation in a disturb ed client by?a.

ensu ring constant client and staff contact 16.lim iting unn ecessary interacti onc.incr easing appropri ate sensory percepti ond.ionb. NurseTri .A 39 year old mother with obsessiv ecompulsi ve disorder has becomei mmobili zed by her elaborate hand washing and walking rituals.

Feelin gs of gui lt and in adequac yd.P roblems with being too conscien tiousb.Pr oblems with anger and remorse c.Feeli ng of unworth iness and hopeless ness17. Mario is complain ing to other clients about not recogniz es that the basis of O. disorder is often:a.

Which of the followin g intervent ions would be mostappr opriate?a .Allowin ga snack to be kept in his roomb.R epriman ding the clientc.Conn ey with borderlin e .Settin g limits on the behavior 18.being allowed by staff tokeep food in his room.I gnoring the clients behavior d.

personali ty disorder who is to be discharg e soonthre atens to ―do somethin g‖ to herself if discharg ed.Discu ss the meaning . Which of the followin gactions by the nurse would be most importan t?a.Ask a family member to stay with the client at home te mporaril yb.

A staff member asks Joey.I gnore the clients statemen t because i t‘s a sign of manip ulation1 9.Joey a client with antisocia l personali ty disorder belches loudly. ―Do you know .Re quest an immedia te extensio n for the clientd.of the client‘s statemen t with her c.

S h a m e d.Depen sivenes sb.Which of the followin g approach es would be most appropri ate to use witha client suffering .Emb arrassm entc .why people find you repulsive ?‖ thisstate ment most likely would elicit which of the followin g client reaction? a.R emorsef ulness20 .

diaphore .L imit sett ingd.Support ive confront ationc.Co nsistenc y21. Rational izationb .from narcissist ic personali ty disorder when discrepa nciesexis t between what the client states and what actually exist?a.Cely is experien cing alcohol withdraw al exhibits tremors.

Lora zepam (Ativan) d. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Whichof the medicati ons would the nurse expect to administ er?a.Halop eridol ( Haldol) 22.Benzl ropine (Cogenti n)c.Nal oxone (Narcan )b.sis andhyper activity.Whic h of the followin g foods would the nurse .

Regul for a ar Coffe clientwh e23.Soda assess d. M i l k b.Con .Trish eliminate from the dietof a client in alcohol withdraw al?a .Re stlessne ss & Irritabili tyc.Whi o is ch of the exhibitin followin g late g would signs of heroin withdraw al?a.Ya wning & diaphor esisb.Ora nge Juic Nurse Hazel e expect to c.

the nurse in charge should?a .To establish open and trusting relations hip with a female client who hasbeen hospitali zed with severe anxiety. Give client fe edback .stipation & steatorr head.Encoura ge the staff to have frequent interacti on with the clientb.Vo miting a nd Diarrhea 24.S hare an activity with the clientc.

Nurse Monette recogniz es that the focus of enviro nmental (MILIE U)therap yis to:a.Man ipulate the envir onment to bring about positive changes inbehavi or b.Role p .about be havior d. Respect client‘s need for personal space 25.Allo w the client‘s freedom to deter mine whether or not they will beinvolv ed in activities c.

Hav e more positive relation with the father than the mother b .Cling to mothe r& cry on separati onc.Be . Use natural r emedies rather than drugs to contro l behavio r 26.lay life events to meet i ndividua l needsd.Nurs e Trish would expect a child with a diagnosis of reactive attachme ntdisorde r to:a.

Have been physical ly abuse27.Is short in durati on & .able to develop only superfici al relation with the othersd. When teaching parents about childhoo d depressio n Nurse Trina shouldsa y?a.It may appear acting out behavior b.Does not respond to conventi onal treatmen tc.

Looks almost identical to adult depressi on28.Spee ch lagc.A 60 year old female client who lives alone tells the nurse at thecomm unity health center ―I really don‘t need . Scannin g speec hb. Shutteri ngd.Nu rse Perry is aware that language develop ment in autistic childrese mbles:a.resolves easilyd.Ec holalia2 9.

anyone to talk to‖.Dis placeme ntb.Deni al30.Proj ection c. NurseTr ish should anticipat .W hen working with a male client sufferin g phobia about black cats.Subli mation d. The TV ismy best friend. The nurse recogniz es that the client is using the defense mechanis m known as?a.

e that a problem for this client would be?a.Anger toward the feared objectc.Lind a is pacing the floor and appears extremel .An xiety w hen discussi ng phobiab . Distorti on of reality when complet ing daily routines 31. Denyin g that the phobia existd.

The mostther apeutic question by the nurse would be?a.W ould you like to watch TV?b.y anxious. Would you like me to talk with you?c. The duty nurseap proache s in an attempt to alleviate Linda‘s anxiety. Ignore t . Are you feeling upset now?d.

Depress ion and a blunte d affect when di scussing .he client32 .Av oidance of situatio n& certain activitie s that rese mble the stressb.Nurse Penny is aware that the sympto ms that distingui sh post traumati cstress disorder from other anxiety disorder would be:a.

Nur se Benjie is commun icating with a male client with substanc einduced persistin g dementi a.the trau maticsit uationc. the client cannot rememb . Lack of interest in family & other sd.Re- experie ncing the trauma in dreams or flashbac k33.

Con fabulat iond.N urse Joey is aware that the signs & sympto ms that would be mostspe . Nurse Benjie is aware that this is typical of?a.Fli ght of facts and fills in the gapswit h imagina ry informat ion.C oncreti sm34. Associa tive loosene ssc.

10% weight loss & alopecia c. excessi ve fears & nausead .Excessi ve activity.Comp ulsive behavio r. memory lapses & an increase d pulse35.Slo w pulse. .cific for diagnosi s anorexia are?a.Ex cessive weight l oss. am enorrhe a & abdo minal distensi onb.

Positiv e body image3 6.Fre quent regurgit ation & reswallow ing of foodb.P revious history of gastri tisc.A characte ristic that would suggest to Nurse Anne that an adolesce nt mayhav e bulimia would be:a.Ba dly stained teethd.Nurse Monette is aware .

Multipl e stimu lib.that extremel y depresse d clients seem to do bestin settings where they have:a.To further assess a client‘s suicidal potential . Nurse Katrina should beespeci ally alert .Rou tine Activiti esc.Min imal decisio n makin g d.Varie d Activiti es37.

He lplessne ss & hopel essness 38.Provi ding a structur ed envir onment .to the client expressi on of:a.A nursing care plan for a male client with bipolar I disorder should include: a. Anger & resentm entc.An xiety & lonelin essd.Fru stration & fear of deathb.

Touchin g the client provide assuran ce39.Desig ning activitie s that will require the clien t to maintai n contact with realityc.W hen planning care for a female client using ritualisti c behavior . Engagin g the client in convers ing about current affairsd.b.

Helps the client focus on the inabilit y to deal with realityb.Is under th e client‘ s consci ous controld .. NurseGi na must recogniz e that the ritual:a. Helps the client c ontrol the anxiety c.Is used by the client primaril y for seconda ry .

A 32 year old male graduate student. After detailed assessm ent. adiagno sis of schizop hrenia is made. It is .gains40. who has become increasi nglywit hdrawn and neglectf ul of his work and personal hygiene. is brought tothe psychiat ric hospital by his parents.

A 23 year old client has been admitted with a diagnosi s of schizop hreniasa ys to the nurse ―Yes.Effe ctive self bounda riesd.Conc rete thinkin gc. March is little woman‖ . That‘s .unlikely that the client willdem onstrate: a.Low self esteem b. its march. Weak ego41.

literal youkno w‖.F light of ideasd.A long term goal for a paranoid male client who has unjustifi ably accused his wife of having many extrama rital affairs would . Looseni ng of asso ciation4 2.Neol ogisms b. These stateme nt illustrate :a.Echo laliac.

Feeli ng of self worthd.Bett er self control to help the clientde velop:a.A male client who is experien cing disorder ed thinking about food beingpoi soned is admitted to the mental health unit. The nurse . Insight into his behavio r b. Faith in his wif e43.

Verbali zing reasons .Using open ended questio n and silencec .Focusi ng on selfdisclosu re of own food preferen ce b.uses whichco mmunic ation techniqu e to encoura ge the client to eat dinner?a .Offerin g opinion about the need to eatd.

Nurse Nina . When Nurse Nina enters the client‘s room.that the client may not choose to eat44.N urse Nina is assigned to care for a client diagnos ed with Catatoni cStupor. the client is found lyingon the bed with a body pulled into a fetal position.

Ask the client direct questio ns to encoura ge talkingb .should? a. Leave the client alone an d continu . Sit beside the client in silence and occasio nally as k openendedqu estiond.Rake the client into the dayroo m to be with other clientsc.

there are no spiders in this room . What should the nurse respond to the client?a. Nurse Tina is caring for a client with delirium and states that ―look at thespide rs on the wall‖. ―You‘re having hallucin ation.e with providin g care to the other cli ents45.

―Wo uld you like me to kill the spiders‖ d. but I do not see spid ers on the wall‖46. ―I can see the spiders on the wall .―I know y ou are frigh tened. but they are not goin g to hurtyou ‖ all‖b. Nurse Jonel is providin g informat ion to a commun .

― Abuse occurs more in lowincome families ‖b.―Ab user use fear an d intimi .―Ab user Are often jealous or selfcentere d‖c.ity group about violence in the family. Which stateme nt by a group member would indicate a needto provide addition al informat ion?a.

―Abus er usually have poor selfesteem‖ 47.dation‖ d.Duri ng electroc onvulsiv e therapy (ECT) the client receives oxygen bymask via positive pressure ventilati on. The nurse assisting with thisproc edure knows that positive pressure ventilati on is .

M uscle rel axations given to preve nt injury during seizure .Dec rease oxygen to the brain increase s confusi on anddisor ientation c.Anes thesia is adminis tered during the procedu reb.Grand mal seizure activity depress es respirati onsd.necessar y because ?a.

When planning the discharg e of a client with chronic anxiety. Which goalwou ld be most appropri ately having been included in the plan of carerequ . Nurse Chrisev aluates achieve ment of the discharg e mainten ance goals.48.activity depress respirati ons.

The client maintai ns contact with a crisis counsel or 49.Th e client eliminat es all anxiety from daily situatio nsb.The client ignores feelings of anxiety c.iring evaluati on?a.The client identifi es anxiety produci ng situatio nsd.N urse Tina is caring .

for a client with depressi on who has not respond ed toantide pressant medicati on.E lectroco nvulsiv e therap y50.Ma rio is a .Neuro leptic medicat ionb. The nurse anticipat es that what treatmen tprocedu re may be prescrib ed a.Sh ort term seclusi onc.Psy chosur geryd.

Name of the .dmitted to the e mergen cy roo m with druginclude d anxiet yrelated to over ingestio n of prescrib ed antipsyc hotic medicati on.b. Length of time on the med. The mostim portant piece of infor mation the nurse in charg e should obtain initially isthe:a.

Name of the nearest relative & their phone number ANSWE RS AND RATIO NALE – PSYCH IATRIC NURSI NG 1. . C .ingested medicat ion & the amount ingested c.Reaso n for the suicide attempt d. Total abstinenc e is the only effective treatment for alcoholis m 2.

D . such as communi cating suicidalt houghts. Halluci nations are visua l. . gustatory . The Nurse should watch for clues. tactile or olfact oryperce ptions that have no basis in reality. auditory. 3.A . and messages . The Nurse has a responsi bility to observe continuo usly the acutely suicidalc lient.

5. Establish ing a consisten t eating plan and monitori ng client‘s weight areimpor tant to this disorder.hoarding medicati ons and talking about death. C . B. staying with the client. Appropri ate nursing intervent ions for an anxiety attack include using shortsent ences. 4. .

Delusion of grandeur is a false belief that one is highly famous andimpo rtant. B .decreasin g stimuli. Individu al with depende nt personali ty disorder typically showsind ecisivene ss submi ssiveness and cling ing behavior . remainin g calm andmedi cating as needed. 6. D . 7.

Clients with schizoty pal personali ty disorder experien ce excessiv e socialanx iety that can lead to paranoid thoughts 9. A . Bulimia disorder generally is a maladapt ive coping response to stress andunder lying issues. 8. B . The .so that ot hers will make decisions with them.

Neuromu scular Blocker. 10. such as SUCCIN YLCHO LINE (Anectin e)produc . 11.client should identify anxiety causing situation thatstimu late the bulimic behavior and then learn new ways of coping with theanxiet y. A . A . An adult age 31 to 45 generates new level of awarenes s.

13. there is little or no emotiona l involvem ent therefore littlealter ation in respirato ry depressio n because it inhibits contracti ons of respirato rymuscle s. therefore they must . With depressio n. D . C . 12. These clients often hide food or force vomiting .

Limiting unnecess ary interactio n will . these electrolyt es areneces sary for cardiac functioni ng. 14. B . 15. These clients have severely depleted levels of sodium and potassiu mbecaus e of their starvatio n diet and energy expendit ure. A .becareful ly monitore d.

The nurse needs to set limits in the client‘s manipula tive behavior to helpthe client . 16. Ritualisti c behavior seen in this disorder is aimed at controlli ng guilt andinade quacy by maintaini ng an absolute set pattern of behavior. C . 17. D .decrease stimulati on and agitation.

A consisten t approach by the staff isnecessa ry to decrease manipula tion. Any suicidal statemen t must be assessed by the nurse.control dysfuncti onal behavior. 19. A . The nurse shoulddi scuss the client‘s statemen t with her to determin e its meaning in terms of suicid e. B . 18.

The nurse would specifica lly use supportiv e confront .. The natural tendency is to counterat tack the threat to self image. 20. When the staff member ask the client if he wonders why others find himrepul sive. the client is likely to feel defensiv e because the question isbelittlin g. B .

C . The nurse would most likely administ er benzodia zepine. such as lorazepa n(ativan) to the client who is experien cing symptom : The client‘s .ation with the client topoint out discrepa ncies between what the client states and what actuallye xists to increase responsi bility for self. 21.

Regular coffee contains caffeine which acts as psychom otor stimulant sand leads to feelings of anxiety and agitation.experien cessympt oms of withdraw al because of the rebound phenome non when thesedati on of the CNS from alcohol begins to decrease. D . 22. Serving coffee top the clientma .

repetitive . Moving to a client‘s personal space increases the feeling .along with muscle spasm. 24. fever. D . abdomin al cramps andbacka che. D . 23.y add to tremors or wakefuln ess. Vomitin g and diarrhea are usually the late signs of heroin withdraw al. nausea.

whichinc reases anxiety. Children who have experien ced attachme nt difficulti es with primaryc aregiver are not able to trust . 25. 26.of threat. C . A . Environ mental (MILIE U) therapyai ms at having everythin g in the client‘ss urroundi ng area toward helping the client.

A .others and therefore relate superfici ally 27. D . 28. The autistic child repeat sounds or words spoken by others. acting outbehav ior. may indicate underlyi ng depressio n. such as temper tantrums. 29. Children have difficulty verbally expressin g their feelings. .

B . 31. The nurse presence . Discussi on of the feared object triggers an emotiona l response to theobject .D . The client statemen t is an example of the use of denial. a defense thatblock s problem by unconsci ous refusing to admit they exist 30. A .

33. Confabul ation or the filling in of . D . Experien cing the actual trauma in dreams or flashbac k is the major sy mptom that distingui shes post traumatic stress disorder from other anxietydi sorder. C . 32.may provide the client with support & feeling of contro l.

Dental enamel erosion occurs from repeated selfinduced vomiting . These are the major signs of anorexia nervosa. Weight loss is excessiv e(15% of expected weight) 35.memory gaps with imaginar y facts is adefense mechanis m used by people experien cing memory deficits. C . A . 34. .

D . 37.36. least stressful and least anxiety producin g. A simple daily routine isthe best. The expressio n of these feeling may indicate that this client is unable tocontinu e the struggle of life. A . Depressi on usually is both emotiona l& physical. B . 38.

Structure tends to decrease agitation and anxiety and to increase theclient‘ s feeling of security. 39. B .A person with this disorder would . The rituals used by a client with obsessiv e compulsi ve disorder helpcontr ol the anxiety level by maintaini ng a set pattern of action. 40.. C .

ons are thoughts that are presente d without D the .not have adequate selfboundari es 41. C . 42. Helping the client to develop . Loose logicalc associati onnectio ns usually necessar y for the listening to interpret the message .

43. 44.feeling of self worth would reduce the client‘sn eed to use patholog ic defenses . B . Open ended question s and silence are strategie s used to encoura geclient s to discuss their problem in descripti ve manner. C .

Clients who are withdra wn may be immobil e and mute. repeated interven tions. The nurse facilitate s commun icationw ith the client by sitting in silence.. and requirec onsisten t. . Commu nication with withdra wn clientsre quires much patience from the nurse.

When hallucin ation is present. D .asking openended question and pausingt o provide opportu nities for the client to respond. the nurse should reinforc e reality with theclient . 46. 45. Person al characte ristics of abuser include low self- . A .

esteem. C . insecurit y and jealousy . 47. 48. A short acting skeletal muscle relaxant such as succinyl choline (Anectin e)is administ ered during this procedu re to prevent injuries during seizure. D . immatur ity.depe ndence. Recogni zing situation .

B . 49. In an emergen .s that produce anxiety allows the client to prepare tocope with anxiety or avoid specific stimulus . D . Electroc onvulsiv e therapy is an effective treatmen t for depressi on that hasnot respond ed to medicati on 50.

cy. The name and theamou nt of medicati on ingested are of outmost importa nt in treating thispote ntially life threateni ng situation . . lives saving facts are obtained first.

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