Final Exam in NCM 104 Situation: A client was rushed to the OR for acute closure glaucoma.

During assessment, you found out that your client experienced acute pain on the left eye. 1. In caring for this client post-op, you monitor for increased intraocular pressure. Which of the following parameters indicate an increased intraocular pressure? a. an intraocular pressure of 20 mmHg c. an intraocular pressure of 15 mmHg b. an intraocular pressure of 22 mmHg d. an intraocular pressure of 26 mmHg 2. Acute closure glaucoma is characterized by which of the following? a. narrowing of the angle between the iris and the cornea b. increased production of aqueous humor c. hyperactivity of the ciliary body d. impairment in the outflow of intraocular fluid 3. In assessing the client’s visual acuity, you will observe which manifestation in those with glaucoma? a. halo vision c. loss of peripheral vision b. clouding and blurring of vision d. presence of floaters in the visual field 4. To confirm the diagnosis of glaucoma, you will expect the physician to order which diagnostic procedure to measure the client’s intraocular pressure? a. visual acuity test c. visual field test b. tonometry d. magnetic resonance imaging 5. In doing health teaching to a client with glaucoma, the following information should be included EXCEPT? a. avoid going to the movie house b. limit driving at night c. instruct the client to continue taking steroidal anti-inflammatory drug d. he may take antitussive medication 6. Development of glaucoma is associated with the following factors EXCEPT: a. African- American race c. client with diabetes mallitus b. family history of glaucoma d. More common among young adults below 40 7. The most common complication of glaucoma is: a. damage to the retinal tissue b. damage to the optic nerve c. drying and scarring of the cornea d. displacement of the lens due to increased intraocular pressure 8. To constrict the pupil and to draw the smooth muscle of the iris away from the canal of schlemm thus permitting the aqueous humor to drain out, the physician will order: a. Midriatrics c. acetazolamide b. atropine sulfate d. miotics 9. To lessen the intraocular pressure by creating a channel to drain the fluid, the physician will perform which of the following procedures? a. iridotomy c. trabeculoplasty b. trabeculectomy d. cyclophotocoagulation Situation: A client was admitted in ER due to progressive loss of vision in one area. After laboratory procedures, the physician diagnosed the client to have retinal detachment. 10. During assessment, you will observe the following manifestations in a client with retinal detachment EXCEPT: a. showering of floaters in the visual field c. darkening of peripheral vision b. progressive blurring of vision d. presence of flashes of light 11. To correct the problem, scleral buckling was done to the client. Which of the following statements correctly describe scleral buckling? a. the vitreous humor is removed from the eye and replaced with a saline solution b. involves placing a silicone band around the eye to hold the retina in place. c. a small gas bubble is injected into the vitreous where it then rises and presses against the retina, thus, closing the tear. d. utilizes cryopexy to seal the detached retina 12. You are doing triage in ER. Among these clients with visual impairment, you will attend first to whom of the following? a. client with corneal inflammation c. client with corneal ulceration b. client with clouding of the cornea d. client with viral conjunctivitis

complete abortion d. mastoiditis is most commonly associated with: a. The most common cause of bleeding during the first trimester of pregnancy are the following.Situation: You are caring for an 8 year-old with chief complaints of fever and pain in the post-auricular area. chromosomal aberration c. you will observe which manifestation? a. EXCEPT: a. anticipatory grieving c. provide low sodium diet b. The result of the otoscopic exam shows congestion in the middle ear. provide bed rest during attack c. With the information presented. Upon delivery of the product of conceptus. it shows elevation of WBC and with CT scan results of inflamed mastoid bone. In preparation for internal examination. threatened abortion d. alert yourself if you will observe which of the following manifestations in the client? a. In the ultrasound. cover the cord with sterile cloth wet with NSS c. ectopic pregnancy d. 24. In caring for client with Meniere’s disease. threatened abortion 25. temperature of 40 C d. incomplete abortion c. stiffness of the neck c. upper respiratory tract infection b. positive drainage on the ear canal b. missed abortion b. extreme maternal age 21. decrease urine output 14. To prevent exacerbation of the disease. You are conducting health teaching to client with Meniere’s disease. 13. Which of the following procedures will most likely be performed? a. CNS infection d. The most common cause of spontaneous abortion is: a. provide dim and quiet environment d. administration of Mg Sulfate . Tympanostomy c. fetal death in uteru 20. Another pregnant mother in 15th week gestation was admitted to the obstetric ward due to vaginal bleeding and uterine cramping. severe tinnitus with nausea and vomiting d. it reveals 3-4 cm cervical dilation. myringotomy b. complete abortion b. administration of RhoGAM c. The most appropriate nursing intervention for the nurse to do is? a. 15. gestational throphoblastic disease b. the mother is having which type of abortion? a. the physician found absence of fetal heart rate and diagnosed the mother to have spontaneous abortion. An ultrasonography was ordered by the physician and the result showed retained of placenta and amniotic membranes. infection of the salivary gland Situation: Care of client with other auditory disorders. loss of balance and dizziness Situation: A 28 year-old primigravida client was admitted to the medical ward due to vaginal bleeding with uterine cramping. the mother suffered from which type of abortion? a. the most characteristic manifestation is? a. inevitable abortion c. gradual hearing loss b. EXCEPT: a. complete bed rest b. 19. In the laboratory. fluid volume deficit d. tympanotomy 16. instruct the mother to have complete bed rest Situation: You were the nurse on duty when a client was admitted due to vaginal bleeding with tissues passed out the vaginal orifice. tinnitus d. With this finding. A client was admitted with hearing impairment. ineffective labor process 23. blighted ovum d. incomplete abortion 22. In routine assessment. unilateral hearing loss c. Vertigo c. Tympanectomy d. CT scan revealed tumor in the left acoustic pathway which is conclusive of acoustic neuroma. The physician ordered for dilation and curettage to prevent further bleeding. bilateral hearing loss b. administration of oxytocin d. risk for infection b. provide stress therapy 18. In the internal examination. The physician ordered for a procedure to facilitate drainage of the middle ear. Spontaneous abortion c. you will anticipate that the physician will order which of the following? a. position the mother in knee-chest position d. In the assessment. middle ear infection c. In the client’s health history. Which of the following nursing diagnoses should be prioritized for a mother who is having an abortion? a. nausea and vomiting 17. you see umbilical cord protruding in the vaginal opening. position the mother on left side lying position b. germ plasma defect b. you should include these information.

80 to100 cc of blood d. A pregnant mother is telling that during the first trimester of her pregnancy. 31. The normal blood loss during menstruation is? a. instruct mother to take soda biscuit d. use of IUD b. In discussing family planning to the mothers. abortion occurs anytime during pregnancy 28. you will associate the development of the disease to: a. One of the mothers asked for ways to prevent abortion for those with history of it. Uterine infection 32. As a nurse. edema and convulsion 36. the most response of the nurse is: a. instruct parents to avoid sexual activity while pregnant c. pelvic inflammatory disease c. 34. padded tongue depressor c. and no edema noted b. proteinuria of +3 to +4 and edema on the face d. toxemia and hypertension c. multiple partner d. 40 to 60 cc of blood 29. abortion occurs after 20th week of gestation b. you included the physiology of menstruation. urinal to limit activity d. shocky manifestations Situation: A client was admitted to the OB ward due to generalized edema that includes the face and the upper extremities. the physician diagnosed the client to have severe pre-eclampsia. proteinuria of +3 to +4. scanty vaginal discharges c. 26. To lessen the discomfort. temperature of 39 C d. edema. throphoblastic tumor c. Which of the following finding is indicative of pre-ecplampsia? a. XXX. padded side rails b. Which of the following findings will you most likely observed? a. 30 to 50 cc of blood c. The following are best responses EXCEPT: a. regular internal examination is required to monitor for dilation of the cervix 27. abortion occurs after the age of viability d. BP of 180/120 mmHg. bleeding in the gums c. 50 to 80 cc of blood b. proteinura of +2 to +3 and no edema noted . monitor for I and O c. early sexual activity 33. hypertension. provide maximum time for bed rest b. Your concern is to implement one of the elements of primary healthcare which is maternal and child health. The physician ordered for urinalysis. In doing you physical examination. the most appropriate nursing management for this is? a. progesterone may be given to the mother d.Situation: You are the rural health nurse in Brgy. Absence of fetal movement is an indication of fetal death in uteru. severe vaginal bleeding b. As a nurse you will prepare which of the following at the bed side? a. you will suspect the mother is having: a. Having this history. BP of 160/110 mmHg. you will refer the client immediately if you observe which of the following? a. instruct to be NPO temporarily to relax the stomach Situation: A mother war rushed to ER due to severe abdominal pain in the right lower quadrant. edema in the lower extremities and proteinuria d. You are discussing ways in monitoring the fetal well being. One of the mothers verbalizes “I had abortion last year when I lost my pregnancy during the 25th week of gestation. abortion occurs before the 20th week of gestation c. hypertension. ectopic pregnanacy d. edema. proteinuria of +2 to +3 with edema noted in the upper extremities c. With presenting manifestations. proteinuria and hypertension b. According to the mother. She has an IUD as a form of contraceptive and had her first intercourse when she was still 16 years old. the client complained for sudden knifelike pain that radiates to the shoulder. You are conducting health education classes to pregnant mothers in the community. BP of 180/120 mmHg. jaundice b. BP of 160/110 mmHg. monitor for electrolyte level b. pillow to prevent head fall 35. After taking nursing health history. After laboratory work-up. severe abdominal pain 30.” With this information. she had morning sickness associated with vomiting. periumbilical echimosis d. her LMP was 8 weeks ago. you found out that she was a prostitute before and was treated for gonorrhea. Which of the following manifestations will support the diagnosis? a. imminent abortion b.

Which of the following findings indicate that the client is developing shock? a. With this assessment finding. The physician ordered magnesium sulfate to be given IM on the buttocks. In physical examination. dropping of coagulation factor 42. prepare the mother for C-S delivery b. aluminum hydroxide c. operating room d. 47. HR of 115 bpm c. Before administering the medication. All of the above 48. placental previa c. it bypasses the lower uterine abnormalities such as varicosities and myomas 46. RR of 24 bpm. anticipatory grieving th Situation: A client who is on the 7 month of her pregnancy was admitted in the OB ward due to severe bleeding. RR of 25 bpm. Your main nursing consideration for this order is? a. History revealed that she had placenta previa. BP of 150/80 mm Hg. instruct the mother to take the medication before going to bed c. you found out that she was diagnosed to have placental previa. it allows the delivery of the fetus regardless of the presentation d. instruct the mother to increase fluid intake to replace the GI losses 45. You are about to give the next dose of magnesium sulfate. D and C pack b. The advantages of this procedure includes the following EXCEPT: a. Which of the following findings will warn you to withhold the medication? a. During the rounds. Which of the following diagnoses should be prioritized for client with pre-eclampsia? a. respiratory rate of 10 bpm d. risk for injury d. there is lesser blood loss and possibility of adhesion c. protamine sulfate d. PR of 50 bpm d. Difficulty of breathing . During the operation. BP of 160/100 mm Hg c. In the history. oxytocin in case of uterine atony 43. HR of 100 bpm d. provide dim light d. the nurse must include all in the intervention plan EXCEPT? a. RR of 11 bpm b. With this procedure. urine output of 20 cc/hour b. discontinue the shaving for you may scraped the lesions Situation: You were the nurse on duty when a client was admitted due to massive bleeding. 41. you noticed lesions on the vaginal wall. calcium gluconate b. PR of 106 bpm b. The physician ordered to give castor oil to relieve the client from constipation. A pregnant client who is on the 3rd trimester of pregnancy went to the hospital with chief complaint of constipation. BP of 90/70 39. which assessment finding indicates referral to the physician? a. allow family visit to provide support b. obtain specimen for culture and sensitivity c. your nursing consideration is: a. With this assessment finding. Another client was admitted with the same complain of sever vaginal bleeding. abruptio placenta d. do clustering of activity c. Your vital signs show shock manifestations. pathologic retraction ring 44. promote complete bed rest 40. Painful uterine contraction dark red vaginal bleeding c. delivery pack c. severe abdominal pain d. the physician made a classical vertical incision on the client’s fundus. epinephrine 38. uterine atony b. the nurse must prepare which medication at bedside? a. A pregnant client went to hospital for scheduled elective C-S delivery.37. fluid volume excess c. perform catheterization to allow the descend of the fetus d. you suspected that the client has? a. Painless uterine contraction with bright red vaginal bleeding b. BP of 120/100 mm Hg. you will anticipate to prepare which of the following? a. To prevent convulsive attack. The physician ordered for Dopamine to be given as side drip. In the delivery room. vaginal delivery is possible for the next pregnancy b. A parturian mother went to the labor room in preparation for delivery. question the physician order b. While shaving the perineal. BP of 80/70 mm Hg. altered cerebral tissue perfusion b. RR of 20 bpm. Which of the following is the classical manifestation of placental previa? a. hypoactivity of the patellar reflex c. you observed a board-like abdomen. tell the mother to save a part of the stool for laboratory examination d. You then suspect she may have herpes infection. the physician performed an internal examination.

49. Nuerogenic shock d. which of the following nursing interventions is most appropriate for the client? a. Base on the findings. Position the client in supine position d. Hypovolemic shock c. Position the client in trendelenburg position c. During vital sings taking. you assume that the client is developing? a. . Cardiogenic shock b. Position the client in knee chest position 50. you noted that the client assumes the temperature of the environment. Septic shock . Position the client on left side lying to promote drainage b. With this.

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