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Diagnostic Examination

Select the best answer for each of the following questions. Read the questions well.

1. Which of the following is NOT a characteristic of an open system?

A. It is self-sufficient and is totally isolated from other systems
B. It exchanges matter, energy or information with the environment
C. It allows sustaining elements to enter the system to nourish it
D. It is easily affected by changes in other systems

2. Body image is:

A. The way a person appears and his style of grooming
B. The way the person looks at a certain age
C. The way a person pictures/perceives his appearance and function and how he compares himself with
D. A body with complete parts and functions

3. The nursing diagnosis BODY IMAGE DISTURBANCE is most likely to be written for which of the following persons?
A. A patient with above the knee amputation
B. A patient with second degree burns
C. A quadriplegic patient
D. A person entering the health care system after moving from wellness to illness

4. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A. Water C. Love and belongingness
B. Freedom from infection D. Self-esteem

5. The “Role Performance Model” of health views that:

A. Health is the absence of signs and symptoms of disease
B. Health is successful adaptation
C. Health is the ability to perform one’s work or job
D. Health is realization of one’s potential

6. Health promotion activities are directed to achieve the following:

1) Increasing level of wellness
2) Improving quality of life
3) Relying on health care personnel to maintain health
4) Promoting healthful lifestyle

A. 1,2,4 C. 1,2,3
B. 2,3,4 D. 1,2,3,4

7. Which of the following is most effective practice by caregivers and family, when caring for a client with low resistance to infection
due to cancer?
A. Allow two visitors only, at a time
B. Wash hands frequently
C. Wear masks in the client’s room at all times
D. Meticulous cleaning of the client’s room

8. The primary why the faucet is considered as contaminated is:

A. It is located in unsterile area
B. Many people are using it
C. It is frequently used
D. It is opened by dirty hands

9. A 14-yar old male is to be admitted to the unit due to high fever related to influenza. With whom among the following clients should
be placed together in the room?
A. The 12-year old male client who had undergone appendectomy
B. The 12-year old female with flu
C. The 12-year old boy with flu
D. The 12- year old boy with leukemia

10. After caring for a client with extensive body burns, the nurse performs which of the following actions when removing protective
A. Remove, mask, gown, gloves, cap and shoe cover
B. Remove gloves, mask, gown, cap and shoe cover
C. Remove gown, mask, gloves, cap and shoe cover
D. Remove cap and shoe cover, mask, gloves, gown

11. Which of the following does not characterize stress?

A. Stress is a nervous energy
B. A single stress does not cause a disease
C. Stress in inherent to life
D. Stress may be protective but at times problematic

12. Adaptive responses of man to stressors are characterized by the following:

1) They are attempts to maintain equilibrium
2) They are fairly uniform in all individuals
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3) They are limitless

4) They are always adequate to overcome stressors

A. 1 and 2 C. 1 and 4
B. 1 and 3 D. 2 and 4

13. The first manifestation of inflammation is:

A. Heat
B. Redness
C. Swelling
D. Pain

14. The primary cause of pain at the site of inflammation is:

A. Release of bradykinin
B. Injury to nerve endings
C. Compression of local nerve endings by edema fluids
D. Impaired circulations

15. The client is in stress because he was told by the physician that he needs to undergo surgery for removal of tumor in his stomach.
Which of the following are effects of activation of the sympatho-adreno-medullary response in the client?
1) Constipation
2) Urinary frequency
3) Hypoglycemia
4) Increased BP

A. 1 and 2 C. 2 and 3
B. 1 and 3 D. 1 and 4

16. The client fell from the stairs, and had twisted her ankle. The injury caused inflammation of the ankle. The nursing interventions for
the inflamed ankle would least likely include which of the following?
A. Elevate the ankle with pillow support
B. Apply warm compress over the ankle for the first seventy-two hours
C. Apply compression bandage over the ankle
D. Administer anti-inflammatory drug as ordered by the M.D.

17. Which of the following events characterize the GAS stage of Alarm?
A. Fight-or-flight response is activated
B. The person regains homeostasis
C. Adaptive mechanisms fail
D. Levels of resistance are increased

18. The first protective cells launched at the site of tissue injury are the:
A. Basophils
B. Eosinophils
C. Monocytes
D. Neutrophils

19. Therapeutic nurse-patient relationship is described as follows:

1) It is based on friendship and mutual interest
2) It is a professional relationship
3) It is focused on helping the patient solve problems and achieve health-related goals
4) It is maintained only as long as the patient requires professional help

A. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4

20. The client has been scheduled to undergo surgery for removal of tumor in her right breast. Which of the following manifestations
indicate that she is experiencing mild anxiety?
A. She has increased awareness of the environment details
B. She focuses on selected aspect of her illness
C. She experiences incongruence of thoughts, feelings and actions
D. She experiences random motor activity

21. The client verbalizes that he is very anxious that the diagnostic tests he had undergone might reveal he has cancer. Which of the
following is most appropriate nursing intervention?
A. Tell the client not to worry unnecessarily, until the results are in.
B. Ask the client to express feelings and concerns with regards to outcome of the tests
C. Reassure the client that everything will be alright
D. Advise the client to divert his attention by watching television or reading newspaper

22. The following are appropriate nursing actions for the elderly with hearing impairment EXCEPT:
A. Speak clearly, in well-enunciated words
B. Use normal tone of voice
C. Repeat instructions as needed
D. Increase loudness of voice when speaking

23. Which of the following colors is difficult to be distinguished by an elderly?

A. Red B. Green
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C. Purple D. Blue

24. Which of the following enhances drug toxicity among elderly?

A. Less acute vision
B. Decreased renal function
C. Altered memory
D. Diminished sense of taste

25. The following are true in the human sexuality of the elderly EXCEPT:
A. There is minimal change in amount of sexual response
B. There is cessation of sexual activity among elderly
C. There is increased refractory periods in male
D. There is reduced vaginal lubrication

26. According to Kohlberg’s theory on moral development, relationships are based on:
A. Mutual trust
B. Mutual satisfaction of needs
C. Mutual approval of each other
D. Mutual beliefs

27. The four concepts common to nursing that appear in each of the current conceptual models:
A. Person, Nursing, Environment, Medicine
B. Person, Health, Nursing, Support System
C. Person, Environment, Health, Nursing
D. Person, Environment, Psychology, Nursing

28. Which of the following is incorrect statement of nursing diagnosis?

A. High risk for ineffective airway clearance related to pneumonia
B. High risk for injury related to dizziness
C. Constipation related to decreased activity and fluids as manifested by small, hard, formed stool every three days
D. Anxiety related to insufficient knowledge regarding surgical experience

29. Which of the following would NOT be a basis for establishing priorities in client care?
A. Actual problems take precedence over potential concerns
B. Attend to equipment and contraptions first, such as IV fluids, urinary catheter, drainage tubes, before the
C. Airway should always be given highest priority
D. Clients with unstable condition should be given priority over those with stable conditions.

30. Which of the following is an incorrect statement of outcome procedure?

A. Ambulates 30 feet with cane before discharge
B. Discusses fears and concerns regarding the surgical procedure during preoperative teaching
C. Demonstrates proper coughing technique after the teaching session
D. Reestablishes normal pattern of bowel elimination

31. The primary factor responsible for body heat production is:
A. Metabolism
B. Release of thyroxine
C. Thyroxine output
D. Muscle activity

32. The heat-regulating center is found in the:

A. Medulla oblongata C. Hypothalamus
B. Thalamus D. Pons

33. The difference between the systolic pressure and the diastolic pressure is:
A. Apical rate
B. Cardiac rate
C. Pulse deficit
D. Pulse pressure

34. When measuring the blood pressure, the following are nursing considerations EXCEPT:
A. Ensure that the client is rested
B. Use appropriate size of BP cuff
C. Initiate and deflate BP cuff 2-3 mm Hg/sec
D. Read upper meniscus of mercury

35. The process involved in the exchange of gases in the lungs is:
A. Diffusion
B. Osmosis
C. Hydrostatic pressure
D. Oncotic pressure

36. Which of the following primarily affects BP?

A. Age
B. Stress
C. Gender
D. Obesity

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Diagnostic Examination

37. A client has just entered the post anesthesia care unit (PACU) from surgery. The postoperative client's immediate needs include
initial monitoring of which of the following items?
A. Vital signs, level of consciousness, and presence of pain
B. Skin coloring, surgical incision, limb movements
C. Skin temperature, blood pressure, mental status
D. Temperature, emotional status, social support

38. The nurse examines the ocular motility of a client who recently experienced a cerebrovascular accident. Follow-up documentation
would describe the function of which of the following cranial nerves?
A. Cranial nerves I, III, and IV
B. Cranial nerves II and V
C. Cranial nerves III, IV, and VI
D. Cranial nerves IV and VII

39. In which of the following positions would it be best to place the client so the nurse can inspect and palpate the Bartholin glands?
A. Semi-Fowler's
B. Sim's
C. Lithotomy
D. Prone

40. A client comes to the walk-in clinic with complaints of abdominal pain and diarrhea. The nurse takes the client's vital signs. The
nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation

41. Heat and acetic acid test is done to determine

A. Presence of albumin in the urine
B. Presence of glucose in the urine
C. Presence of ketones in the urine
D. Presence of RBC in the urine

42. The right lung has:

A. 2 lobes C. 4 lobes
B. 3 lobes D. 5 lobes

43. The correct site at which to verify a radial pulse measurement is the:
A. Brachial artery
B. Apex of the heart
C. Temporal artery
D. Inguinal site

44. Cheyne-Stokes breathing is:

A. Slow, shallow respirations which result to inadequate alveolar ventilation
B. Difficulty of breathing in reclining position
C. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and
temporary apnea
D. Shallow breaths interrupted by apnea

45. The best position to promote maximum lung expansion is:

A. Supine
B. Retractions
C. Noisy breathing
D. Semi fowler’s

46. The characteristic manifestation of airway obstruction is:

A. Bradypnea
B. Retractions
C. Noisy breathing
D. Tachypnea

47. To evaluate effectiveness of suctioning, the nurse should primarily:

A. Auscultate the chest for clear breath sounds
B. Assess the respiratory rate
C. Check the skin color
D. Palpate the pulse rate

48. Prolonged deficiency of Vitamin B12 leads to:

A. Beriberi
B. Pernicious anemia
C. Pellagra
D. Peripheral neuritis

49. The vitamin necessary for absorption of calcium is:

A. Vitamin D C. Vitamin C
B. Vitamin A D. Vitamin E

50. Vitamin K is necessary for:

A. Bone and teeth formation
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B. Integrity of skin and mucous membrane

C. Blood coagulation
D. Formation of RBC

51. The length of NGT to be inserted is correctly measured;

A. From the tip of the nose to the umbilicus
B. From the tip of the nose to the xiphoid process
C. From the tip of the nose to the earlobe to the umbilicus
D. From the tip of the nose to the earlobe to the xiphoid process.

52. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms

53. A scrub nurse in the operating room has which responsibility?

A. Positioning the patient
B. Assisting with gowning and gloving
C. Handling surgical instruments to the surgeon
D. Applying surgical drape

54. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A. 39 degrees C C. 38.9 degrees C
B. 47 degrees C D. 40.1 degrees C

55. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis

56. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm
is true?
A. The bell detects high-pitched sounds best
B. The diaphragm detects high-pitched sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched sounds best

57. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The
nurse in charge should run the I.V. infusion at a rate of:
A. 15 drop per minute
B. 21 drop per minute
C. 32 drop per minute
D. 125 drops per minute

58. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A. Radial C. Femoral
B. Brachial D. Carotid

59. Which of the following is most effective nursing measure to relieve urinary retention?
A. Allow the patient to listen to the sound of running water
B. Dangle fingers in warm water
C. Provide privacy
D. Pour warm water over perineum

60. Which of the following initiates voiding?

A. Valsalva maneuver
B. Increased intraabdominal pressure
C. Sympathetic response stimulation
D. Parasympathetic response stimulation

61. Which intervention is an example of primary prevention?

A. Administering digoxin (Lanoxicaps) to a patient with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou smear to screen for cervical cancer
D. Using occupational therapy to help a patient cope with arthritis

62. Which statement regarding heart sounds is correct?

A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is loudest at the base

63. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation

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Diagnostic Examination

64. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this
client would be to:
A. Assess the client’s airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow

65. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit
(HCT), 40%. Which goal would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury

66. The following are characteristics of basic human needs EXCEPT:

A. Priorities are uniform to all individuals
B. Needs may be met in different ways
C. Needs are interrelated
D. Needs may be deferred

67. The following are concepts of health:

1) Health is a state of complete physical, mental, and social well being and not merely the absence of disease or
2) Health is the ability to maintain balance
3) Health is the ability to maintain the internal environment
4) Health is the integration of all parts and subparts of an individual

A. 1,2,3
B. 1,3,4
C. 2,3,4
D. 1,2,3,4

68. The “Health-Illness Continuum Theory” describes which of the following:

1) The effect of environment to well-being and illness
2) High level wellness is achieved if a person is able to function independently
3) Precursor of illness may be hereditary, environmental and behavioral factors
4) The relationship between agent, host and environment

A. 1,2,3,4
B. 1,3,4
C. 1,2,3
D. 2,3,4

69. Which of the following teachings methods is most appropriate for teaching a diabetic client on self-injection of insulin?
A. Detailed explanations
B. Demonstration
C. Use of pamphlets
D. Filmstrip

70. When using printed material to teach diabetic patient about foot care, the nurse should:
A. Read the material to the patient
B. Allow the patient to read the material
C. Read the material to evaluate its clarity, accuracy and effectiveness
D. Give the material to a family member to read the patient

71. Florence Nightingale conceptualizes that nursing is:

A. The act of utilizing the environment of the patient to assist him in his recovery
B. Assisting the individual, sick or well, in the performance of those activities contributing to health, preventing illness and
rehabilitating the sick or disabled
C. A humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness and
rehabilitating the sick or disabled
D. A unique profession in that it is concerned with all the variables affecting an individual’s response to stressors.

72. According to Havighurst’s theory on developmental tasks, the following are tasks of a 65-year old person EXCEPT:
A. Adjusting to retirement and reduced income
B. Adjusting to decreasing Physical strength and health
C. Establishing an explicit affiliation with one’s age group
D. Adjusting to aging parents

73. The client with fever had been observed to experience elevated temperature for few days, followed by 1 to 2 days of normal range
of temperature. The type of fever he is experiencing is:
A. Intermittent fever
B. Relapsing fever
C. Remittent fever
D. Constant fever

74. The following are contraindications to oral temperature taking EXCEPT:

A. Dyspnea
B. Diarrhea
C. Nasal-packing
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D. Nausea and vomiting

75. Which of the following nursing actions is inappropriate when taking the rectal temperature?
A. Assist client to assume lateral position
B. Lubricate thermometer with water-soluble lubricant before use
C. Hold the thermometer in place for 2 minutes
D. Instruct to strain during insertion of the thermometer

76. The following are appropriate nursing actions when performing physical health examination to a client EXCEPT:
A. Ensure privacy of the client throughout the procedure
B. Prepare the needed articles and equipment before the procedure
C. Assess the abdomen following this sequence: right lower quadrants
D. When assessing the chest, it is best to place the client in side lying

77. Which of the following is inappropriate nursing action when collecting clean-catch midstream urine specimen for routine urinalysis?
A. Collect early morning, first voided specimen
B. Do perineal care before collection of specimen
C. Collect 5-10 mls of urine
D. Discard the first flow of urine

78. Which of the following nutrients remains in the stomach for the longest period?
A. Fats
B. Proteins
C. Carbohydrates
D. Water

79. The accumulation of hardened, putty-like fecal mass at the rectum is

A. Obstipation
B. Constipation
C. Tympanities
D. Fecal impaction

80. Which of the following is the richest source of iron?

A. Mongo
B. Milk
C. Malunggay leaves
D. Pechay

81. To assess the adequacy of food intake, which of the following assessment parameters is best used?
A. Food preferences and dislikes
B. Regularity of meal times
C. 3-day diet recall
D. Eating style and habits

82. Kwashiorkor is a condition characterized by:

A. Calorie deficiency
B. Vitamin Deficiency
C. Protein deficiency
D. Mineral deficiency

83. The oxygen administration device preferred for patients with COPD is:
A. Nasal cannula
B. Oxygen tent
C. Venturi mask
D. Oxygen hood

84. The maximum time for applying suction is:

A. 5-10 seconds
B. 10-15 seconds
C. 15-20 seconds
D. 20-30 seconds

85. Which of the following nursing actions is inappropriate when providing steam inhalation therapy?
A. Check doctor’s order
B. Cover the eyes with moist washcloth
C. Place the spout 3-4 inches away from the patient’s nose
D. Place the patient in semi-fowler’s position

86. Which of the following nursing theorists conceptualizes that all persons strive to achieve self-care?
A. Sister Callista Roy
B. Dorothea Orem
C. Dorothy Johnson
D. Jean Watson

87. Which of the following nursing theorists introduced Transcultural Nursing Model?
A. Imogene King
B. Dorothea Orem
C. Dorothy Johnson
D. Madeleine Leininger

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Diagnostic Examination

88. The most important communication skill to be developed by the nurse manager except.
A. Performing bedside nursing
B. Assertiveness
C. Questioning
D. Attentive Listening

89. Which of the following moral theories is based on respect for other humans and belief that relationships are based on mutual trust?
A. Erikson’s Theory
B. Kolberg’s Theory
C. Freud’s Theory
D. Schulman and Mekler’s Theory

90. The caregiver role of the nurse emphasizes:

A. Implementing nursing care measures
B. Providing direct nursing care
C. Recognition of needs of clients
D. Observation of the client’s responses to illness

91. The nurse takes the patient’s advocate role when she:
A. Defends the rights of the patient
B. Intercedes on behalf of the patient
C. Refers the patient to other services
D. Works with the significant others

92. The manager role of the nurse is best demonstrated when she:
A. Plans nursing care with the patient
B. Intercedes on behalf of the patient
C. Refers the patient to other services
D. Works with the significant of others

93. All of the following are primary responsibilities of the nurse manager EXCEPT
A. Performing bedside nursing
B. Coordinating and delegating patient care
C. Setting standards of performance
D. Designating staff schedules

94. A nurse providing teaching on weight reduction compliments the client on exercising daily. This action will promote the teaching
plan by providing the client with which of the following?
A. Positive reinforcement
B. Feedback on client behavior
C. Empathy towards the client
D. Reassurance to the client

95. A nurse is preparing to administer intravenous medication through a port in the intravenous infusion line. This technique would
require the nurse to use which of the following infection control measures?
A. Standard precautions
B. Clean technique
C. Sterile technique
D. Contact precautions

96. A client with a colostomy is asking the nurse about the types of foods that may loosen stool and cause leakage into the pouch.
Which of the following foods should the client be told to include in the diet to prevent this problem?
A. Asparagus, beans, eggs, fish, onions
B. Applesauce, bananas, rice, tapioca, yogurt
C. Fried foods, highly spiced foods, raw fruits and vegetables
D. Carbonated drinks, fruit juices, greasy and pureed foods,

97. The nurse has been instructed to obtain informed consent from a client who will be undergoing a surgical procedure. What is the
most essential information to include in the discussion prior to the client signing the permission?
A. The client's diagnosis
B. Treatment proposed and the cost
C. The technical aspects of the procedure
D. Right to withdraw consent

98. To administer 1 mL of a flu vaccine intramuscularly (IM) to an obese adult in the deltoid area you would use what size needle?
A. 5/8 inch.
B. 1 inch.
C. 1-1/2 inch.
D. 2 inch.

99. A sudden redness of the skin is known as:

A. Flush
B. Cyanosis
C. Jaundice
D. Pallor

100. The rate of Living Theory of Aging conceptualizes that:

A. Changes in replication of DNA –RNA are the causes of aging
B. Aging is caused by a change in the immune system
C. The body is like a machine, parts wear out and the machine breaks down
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D. The faster one lives, the sooner one ages and dies

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