Professional Documents
Culture Documents
NURSING PRACTICE I
1. ANSWER: A- Although letters b, c, and d are also functions of community health nursing, health promotion is the primary focus of CHN practice especially
in maintaining the people’s OLOF. (Nisce, et al, 2001).
2. ANSWER: C- According to Nisce, et al (2001), drug abuse and lifestyle diseases are the emerging and pressing health problem being seen in the
communities among higher income groups.
3. ANSWER: A- Persons form low-income groups are the one’s mostly served by the CH nurses because they have greater number of illness and health
problems (Nisce, et al, 2001).
4. ANSWER: D- Environmental influences refer to air, water, food, water waste, noise, radiation and pollution (Nisce, et al, 2001).
5. ANSWER: D- Political factors include safety, oppression, and people empowerment (Nisce, et al, 2001).
6. ANSWER: B- One qualifies for this position with the following: BSN, RN, Masters Degree in Nursing/Public Health and 5 years experience as a PHN.
7. ANSWER: D- The qualifications of a regional nurse supervisor are: BSN, RN, five years experience in CHN with 2 years in a supervisory position
8. ANSWER: A- The qualifications of a chief nurse in city health departments and health offices are: BSN, RN, master’s degree in nursing major in CHN or
Master’s degree in Public Health major in CHN administration , 5 years experience, 3years supervisory with leadership ability
9. ANSWER: B- Community health nurses are generalist as they provide a wide range of nursing responsibilities to different types of patients (Nisce, et al,
2001)
10. ANSWER: D- COUNSELOR-TTS: WORD MIRRORING (COUNSEL)
11. ANSWER: A- The JOINT AGENCIES OF THE DEPARTMENT OF LABOR believes in the positive socio-cultural value of VOLUNTEERISM
synonymous with the FILIPNO CUSTOM called “BAYANIHAN”, the DOLE shall not cause the deprivation and instead further encourage the
continuance of this practice among Filipino workers and in the enhancement of our “positive character” as Filipinos. Volunteerism MUST not be seen as
a wrongful act among nurses or any Filipino worker. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
BONonNurseVolunteerism.pdf
12. ANSWER: B- The JOINT AGENCIES OF THE DEPARTMENT OF LABOR however reminds all concerned (Nurses and Administrators of Healthcare
Institution accepting volunteers) that in such practice there exist NO EMPLOYER-EMPLOYEE RELATIONS nevertheless the doctrine of respond eat
shall ipso facto apply in any or all ethico-legal cases which may be encountered by both parties in such practice;In adherence to the Philippines
Nursing Core Competency Standards with the 11 Key Areas of Responsibilities of every Filipino nurse and considering the “volunteer nature of nursing
services” provided by the so called volunteer nurses, Nursing Service Administrators are reminded of the extent of responsibilities and accountabilities
of volunteer nurses while on volunteer practice. The Board of Nursing SHALL, when ethico-legal issues arise, ALWAYS LOOK INTO, whenever
applicable, the extent of the “respond eat superior” responsibilities and accountabilities of the various Nursing Services.
Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC= BONonNurseVolunteerism.pdf
13. ANSWER: D- “mindful of the application of Art:72, Chapter 1, Title II of the Philippines LABOR CODE”, or the lack of application or violation thereto
especially on the use of on-the-job-training. We strongly exhorts hospitals and/or health institutions that are affected nurses already fall under the
category of “Registered Professionals” and therefore DESERVE TO BE PAID RIGHTFUL SALARIES to provide them the dignity of earning a decent
living befitting their status as “PROFESSIONAL NURSES”. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
BONonNurseVolunteerism.pdf
14. ANSWER: C- The BOARD OF NURSING, with its rule-making authority under the Philippines Nursing Act (R.A.. 9173), SHALL issue the necessary
Guidelines for all POST-BASIC/POST-GRADUATE NURSING TRAINING PROGRAMS to establish legitimacy in adherence to its new National
Nursing Career Progression Policy; Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC= BONonNurseVolunteerism.pdf
15. ANSWER: D. - Concerned therefore with current and evolving events the Board of Nursing issues the following statements: PRAMOUNT
CONSIDERATION should be “safety and quality” of nursing services under the so-called VOUNTEER PRACTICE which is directly proportional with the
Ethico-Moral-Legal Dimensions of this Practice. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
BONonNurseVolunteerism.pdf
16. ANSWER: A- Philippine Health Corporation (Philhealth)- Philhealth should pay for the project’s nurse’s cooperatives for their services rendered to its
members. The OHNAP refers qualified patients from their companies to their company-based clinics to the cooperative, The PRC-Board of Nursing
promotes nurse entrepreneurship among the country’s nursing students and schools and research on the feasibility of including nurse entrepreneurship
in the BSN curriculum. The DOLE provides general management and direction. Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project
EntrepreNURSE.
17. ANSWER: C- 1,2,3,4- Rationale: All of the above are recipients of the project EntrepreNURSE. Reference: PRC Souvenir Program, Nov 2009 NLE,
Project EntrepreNURSE.
18. ANSWER: D- 1,2,3 Rationale: An initiative of DOLE, in collaboration with BON-PRC, DOH, PNA, UPCN, OHNAP and other government and non-
government entities to promote nurse entrepreneurship by introducing a home health care industry in the Philippines: 1) to reduce the cost of health
care for the country’s indigent population by bringing primary health care services to poor rural communities, 2) to maximize employment opportunities
for the country’s unemployed nurses and 3) to utilize the country’s unemployed human resources for health for the delivery of public health services and
the achievement of the country’s Millennium Development Goals on maternal and child health, consistent with the FourMULA One for Health framework
of the Department of Health. Reference: www.dole.gov.ph and Project EntrepreNurse
19. ANSWER: A- Form cooperatives and manage nurse’s clinic- An initiative of DOLE, in collaboration with BON-PRC, DOH, PNA, UPCN, OHNAP and
other government and non-government entities to promote nurse entrepreneurship by introducing a home health care industry in the Philippines.
Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project EntrepreNURSE.
20. ANSWER: B- Maternal and child health- To utilize the country’s unemployed human resources for health for the delivery of public health services and
the achievement of the country’s Millennium Development Goals on maternal and child health, consistent with the Fourmula One for Health framework
of the Department of Health. Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project EntrepreNURSE.
21. ANSWER: C- The two subspecialties of CHN in the Philippines are School Health Nursing and Occupational Health Nursing (Maglaya, A.(2004). Nursing
Practice in the Community.
22. ANSWER: D- The determinants of School Health Nursing are characteristics of clientele, policies of DepEd, programs of DOH and nursing standards.
23. ANSWER: A- Life expectancy of female has always been higher than males: females 72.8 years and males 67.53 years. Reyala, et al. (2007). Public
Health Nursing in the Philippines.
24. ANSWER: B- The Department of Health provides care services to the people in all the three levels of prevention. Maglaya, A. (2004). Nursing Practice in
the Community.
25. ANSWER: B- Case finding, cataract screening, TB multiple drug therapy, ORT and sputum microscopy are examples of secondary level of prevention.
Maglaya, A. (2004). Nursing Practice in the Community.
26. ANSWER: D- The risk of developing clinical disease is 6-12 months after exposure. TB may persist undetected for a lifetime as a latent infection with the
patient capable of transmitting it to others unknowingly. Nisce, et al (2001). Community Health Nursing Services in the Philippines.
27. ANSWER: B- Modes of transmission of TB is by the following:
Airborne by droplet nuclei through sneezing, talking and coughing. Persons with cavity lesions are highly infectious because their sputum contains
1 million to 10 million bacilli per mL.
Prolonged contact with the patient by household members
Direct contact by kissing
Direct invasion of microorganism to breaks in the skin Nisce, et al (2001). Community Health Nursing Services in the Philippines.
36. ANSWER: B- Lactating women are given iron supplementations preferably for for 3 mos or 90 days AND PREGNANT WOMAN FOR 6 months
37. ANSWER: B- Children with malnutrition are given Vitamin A capsule OR 200,000 IU
38. ANSWER: D- Iodine, iron and vitamin A
39. ANSWER: B. LOI 441- Integration of Nutrition Education in the school curriculum. A- PD No. 491- declared July as the Nutrition Month and creation of
National Nutrition Council, C- RA 8976- Philippine Food Fortification Act of 2000. D- EO 382- November 7 declared National Food Fortification Day
40. ANSWER: B- Iron supplementation for low birth infants will start at 2 MONTHS However, VLBW infants fed mother’s own milk or donor human milk should
be given 2–4 mg/kg per day iron supplementation starting at 2 weeks until 6 months of age.
41. ANSWER: A- NBS is done after 48 – 72 hours after birth because PKU cannot be detected as early as 24 hours giving a false negative result.
42. ANSWER: A- Newborn screening is performed by getting a blood sample using the heel prick method. The said test can now be charged to Philhealth with a
rate of 1,600 pesos
43. ANSWER: C- AMONG THE DISEASES INCLUDED IN THE NBS, MSUD and CAH will lead to death if not detected or treated.
44. ANSWER: A- Individuals deficient in G6PD are usually asymptomatic; however, in some cases exposure to chemicals (for example, naphthalene) and
drugs (including sulfamides, antipyretics, nitrofurane, primaquine and chloroquine) can induce massive intravascular hemolysis. Among the clinical
forms of this enzymatic deficiency are jaundice, acute hemolytic anemia and chronic nonspherocytic hemolytic anemia. A more severe consequence of
neonatal hyperbilirubinemia is kernicterus, a neurological syndrome caused by the deposition of bilirubin in the brain tissues, which results in severe
consequences and even death.
45. ANSWER: B - Infants with this disease seem healthy at birth but quickly deteriorate, often with severe brain damage, which may be permanent. Death
often occurs within the first five months in severe cases of the disease, when left untreated.
46. ANSWER: D- Local health systems development
47. ANSWER: A- Integrated prevention and control of lifestyle related diseases
48. ANSWER: C - Award for excellence refers to the highest level quality standards
49. ANSWER: C- Second level quality standards for the 4 core public health programs are met
50. ANSWER: D- The pillars of sentrong sigla movement are: Quality assurance, Grants and technical assistance , Awards – Sentrong Sigla Movement seal
and Health promotion
51. ANSWER: A - P.D. 522- Mandatory implementation of sanitary permit to all food establishments; City Hall), R.A. 9003- The discipline associated with
the control of generation, storage, collection, transfer and transport, processing, and disposal of solid wastes in a manner that is in accord with the best
principles of public health economics, engineering, conservation, aesthetics and other environmental considerations, P.D. 442- Labor Code on
Prevention and Compensation. E.O. 307 - creating occupational safety and health center (OSHC)
52. ANSWER: B- Solid particles in the water binds to alum (Tawas) and settles at the bottom
- Sedimentation - Let it stand for a few hours and the solid particles will settle at the bottom of the container
- Filtration - Use of filters
- Fluoridation – Adding of fluoride to water
53. ANSWER: C- A point source facility normally serves 15-25 households and its outreach must be Within 250m from the farthest user
54. ANSWER: B- Yellow with black band - pharmaceutical, cytotoxic, or chemical wastes (labeled separately)
-Black or colorless - non-hazardous, non-biodegradable wastes, plastic covers, IV glass bottles
-Green - non-hazardous biodegradable wastes, leftovers
-Yellow with biohazard symbol - pathological/anatomical wastes
-Yellow bag that can be autoclaved - infectious wastes
-Orange with radioactive symbol - radioactive wastes
-Red - sharps, needles
-Yellow - tissues, syringe
55. ANSWER: C- an acceptable toilet should not allow the entry and exit of small animals. All other options are correct.
56. ANSWER: B- Locally Endemic disease control
57. ANSWER: B- Expanded Program on Immunization
58. ANSWER: D. Maternal and Child Health
59. ANSWER: C- Nutrition
60. ANSWER: D- ALL ARE INCLUDED. Suyurin at sirain ang pinamumugaran ng mga lamok, Sarili ay protektahan laban sa lamok, Sumangguni agad sa
pagamutan kapag may sintomas na ng dengue, Sumuporta sa “fogging/spraying” kapag may banta na ng outbreak
61. ANSWER: B- It is the birth attendant who must fill-up and register the birth of the infant. If the birth attendant is a hilot ot TBA, she must be assisted by
the midwife. The TBAs must report to the health center or BHS all deliveries that she assisted for continuing services. Reyala, et al. (2007). Public
Health Nursing in the Philippines.
NURSING PRACTICE 2
1. ANSWER: D- The goal here is to relieve pressure on the cord from the presenting part. This can be accomplished by manually holding the presenting part
off the cord through exerting upward pressure on the presenting part. With many complications, it helps to have the woman assume the side-lying position.
In this case, however, that may not be enough to relieve pressure on the cord. She should be put in a deep Trendelenburg’s or a modified Sims’ position.
Stimulating the fetal scalp or using acoustic stimulation is sometimes called for when a nonreassuring fetal heart rate pattern is seen on the monitor. The
client shouldn’t push because that would result in pressure on the cord.
2. ANSWER: D - A client with a second episode of bleeding from a placenta previa usually needs to undergo cesarean delivery, and a CBC is necessary to
determine hemoglobin level before surgery; an order for packed RBCs will ensure replacement blood is available in case it’s needed. A scalp electrode can’t
be used because the placenta blocks access to the fetus. Vaginal examinations could promote vaginal bleeding by disturbing the placenta. The client should
remain on bed rest, and the bladder will be emptied when an indwelling urinary catheter is inserted before surgery.
3. ANSWER: B- The most accurate answer is the one that explains that several factors work together to cause labor to begin. Telling the woman that it is a
mystery is not entirely accurate because, although we don’t have all the answers, scientists do have a partial understanding of the forces that affect labor. If
3 |MOCKBOARD 2018- PART 2 GLOCAL REVIEW & TUTORIAL CENTER INC.
FINAL MOCKBOARD ANSWERS AND RATIONALE
there is a special hormone that signals labor to begin, it has not been discovered. Telling the woman not to worry about it is not therapeutic and dismisses her
concern unnecessarily.
4. ANSWER: C-Each woman experiences labor pain in a unique way. The “best” method is the method that coincides with the woman’s belief system and
works for the woman. It is best to learn several methods because it is difficult to predict which method will be most beneficial for the woman until she actually
experiences labor. Stating that an epidural is the best or that natural childbirth is best attempts to impose the nurse’s beliefs about labor pain management on
the woman. Stating that most women require some type of IV pain medication during labor is incorrect. Many women go through labor without IV pain
medications.
5. ANSWER: B- Counter-pressure on the lower back and intradermal water injections are interventions that are specifically indicated for intense back labor.
Intermittent labor support and reassurance that the pain is temporary are not particularly helpful for any type of labor pain. Effleurage and ambulation
generally are more helpful in early labor and are not specific to back labor. Hypnosis and imagery require special training and are not specific to back labor.
6. ANSWER: C- The more milk is removed from the breasts, the more milk will be produced. For a non-lacting mother, the breasts should not be pumped nor
manually expressed in order not to stimulate more milk secretion causing more engorgement. Cold application, instead of warm compress is used to relieve
engorgement and discomfort. Medication to relieve pain and suppress milk production may be taken as ordered.
7. ANSWER: B- Breastfeeding is best to promote mother-newborn bonding. To enhance the letdown reflex or milk ejection reflex, which is affected by material
emotions, the nurse should make sure that the lactating mother receives adequate support and reassurance. The best schedule for feeding infants is not rigid
(not necessarily every 2 hours or every 3 hours), but ‘on demand.’ Demand feeding the infant according to his biologic need for food. In the event that the
mother decides to bottlefeed the infant, she should be advised to cuddle/hold the infant while feeding, in order to have the most important prerequisite to
bonding-eye contact.
8. ANSWER: C- If the woman perceives negative attitude from others, she may be tense and letdown may not occur. A positive attitude of others toward
breastfeeding promotes relaxation and letdown reflex, the most important to successful breastfeeding. Prolactin (or milk secretion) reflex is enhanced by
complete emptying of the breasts with each feeding time.
9. ANSWER: B- Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C,
and D – those with diabetes, hypertension, and thyroid disease – can be allowed to breastfeed.
10. ANSWER: D- Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the
breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing
to do with success, so answers A, B, and C are incorrect.
11. ANSWER: C- The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering
oxygen is also indicated. Answer A is not called for at this time. Answer B is incorrect because it is not needed, and answer D is incorrect because there is no
data to indicate that the monitor has been applied incorrectly.
12. ANSWER: A- Eating carbohydrates such as dry crackers or toast before arising helps to alleviate morning sickness. Answer B is incorrect because the
additional fat might increase the client’s nausea. Answer C is incorrect because the client does not need to skip meals. Answer D is the treatment of
hypoglycemia, not morning sickness; therefore, it is incorrect.
13. ANSWER: C- The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the
client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.
14. ANSWER: C- The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately
400mg of calcium.
15. ANSWER: C- Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby
should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is
incorrect.
16. ANSWER: C- Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder decreases the progression of labor. Answers A,
B, and D are incorrect because the bladder does not fill more rapidly due to the epidural, the client is not in a trancelike state, and the client’s level of
consciousness is not altered, and there is no evidence that the client is too embarrassed to ask for a bedpan.
17. ANSWER: C - The obstetrical client under age 18 is at greatest risk for CPD because pelvic growth is not fully completed. Answers A, B, and D are incorrect
because these clients are not as likely to have CPD.
18. ANSWER: C- Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will
have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B,
postural hypertension, is not likely. Answer D, hematuria, is not related to epidural anesthesia.
19. ANSWER: A- Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D
are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic.
20. ANSWER: B- Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the
release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for
conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the
beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
21. ANSWER: B- In the first 7 to 14 days the developing ovum is known as a blastocyst; it is called an embryo until the 8th week; the developing cells are then
called fetus until birth. A- heard between the 12th and 20th week. C- this is called blastocyst.
22. ANSWER: D- the function of progesterone is to relax the uterus and maintain a succulent endometrium to foster implantation of the fertilized ovum. A-
Ovulation is stimulated by increases in the level of leutinizing hormone (LH) and estrogen. B- Menstruation is controlled by regulating factors from the
hypothalamus and pituitary (FSH-RH, FSH, LH-RH, LH); these hormones stimulate the production of ovarian follicles, ovulation, estrogen, and progesterone
by the ovarian cells. C- Capillary fragility is often associated with deficiency of vitamin C (ascorbic acid); progesterone is not responsible.
23. ANSWER: B- Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the
release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for
conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the
beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
24. ANSWER: A- The greatest danger of drug-induced malformation is during the first trimester of pregnancy, because this is the period of organogenesis. B-
this may cause problems, but organogenesis has already taken place by the second trimester. C- the fetus is totally formed at this time, and damage from
drugs would not be likely. D- Drugs should be avoided throughout pregnancy, but the first trimester (period of organogenesis) is the most critical.
25. ANSWER: C- Progesterone stimulates differentiation of the endometrium into a secretory type of tissue. A- influenced by estrogen. B- influenced by high
levels of lutenizing hormone. D- influenced by testosterone.
26. ANSWER: D- ALL ARE CORRECT.
27. ANSWER: A- Early deceleration is due to fetal head compression causing vagal nerve stimulation and only needs further assessment or to continue
observation
28. ANSWER: B- Presence of acceleration denotes fetal well-being.
29. ANSWER: C: FHR strip shows a late deceleration and is caused by uteroplacental insufficiency
30. ANSWER: C- positioning the mother on her left side relieves pressure on the inferior vena cava increasing blood flow to the heart for increased cardiac
output and promotes adequate maternal and fetal circulation
31. ANSWER: D- Most drugs pass into breast milk and almost all medications appear in only small amounts in human milk. Very few drugs are contraindicated
for breastfeeding women. The physician must be fully advised so an appropriate recommendation can be made.
32. ANSWER: B- Its immune globulins (IgA) protects the baby against all common childhood diseases in the first two months of life.(NO RATIO)
NURSING PRACTICE 3
1. ANSWER: D- Improve the patient’s immune function
2. ANSWER: C- "Do you use any injectable drugs or have sexual activity?”
3. ANSWER: D- A needle-stick with a needle and syringe used to draw blood
4. ANSWER: B- How to prevent transmission between sexual partners
5. ANSWER: B- Varicella zoster immune globulin
6. ANSWER: B- Option C is incorrect; infection can be transmitted to the child in utero or through breastmilk. Option A is incorrect; social isolation should be
minimized. No isolation precautions are needed to enter the room to talk to the patient. Option B is correct; standard and contact precautions should be
practiced because transmission is through blood or bodily fluids. Option D is incorrect; HIV is not an airborne infection, and not treated with antibiotics.
7. ANSWER: A- Option A is correct; immunosuppression is one of the main concerns in patients with HIV. Prevention of infection is very important to avoid
serious complications. Even though this is only a potential diagnosis and not an actual one, this still should be of priority because opportunistic infections can
be fatal for the patient. Option B is incorrect; this can be a problem for the patient but risk for infection should be prioritized more. Options C and D are
incorrect; these are psychosocial problems and is of secondary in priority.
8. ANSWER: A- Option A is correct; nurses are responsible for protecting the patient’s right to privacy by safeguarding confidential information. Confidentiality is
basic to therapeutic relationship and is a client’s right. Inadvertent disclosure of confidential patient information may result in personal, financial, and
emotional hardships for HIV-infected individuals. Option B and C are incorrect; these do not maintain confidentiality. Option D is incorrect; this is a blunt
statement and does not acknowledge the issue.
9. ANSWER: A- Option A is correct; avoid foods that stimulate intestinal motility, such as vegetables and fruits, fatty, spicy, and sweet foods, alcohol, and
caffeine. Option B is incorrect; small, frequent meals are better tolerated. Option C is incorrect; lactose intolerance can contribute to diarrhea. Option D is
incorrect; drink lots of fluids, especially between meals.
10. ANSWER: B- Option B is correct; pulmonary therapy consists of deep breathing, coughing, postural drainage, percussion, and vibration should be done
every 2 hours to prevent stasis of secretions and promote airway clearance. Option A is incorrect; tepid sponge bath can help bring the temperature down.
Analgesics may also be given. Airway is of priority. Option C is incorrect; fluid loss can be replaced through oral fluid intake of 3L a day. Invasive procedures
must be avoided if the patient can tolerate fluids orally. Option D is incorrect; relaxation techniques can help relieve anxiety but airway is of priority.
11. Answer: B- Western blot assay is used to confirm seropositivity of the ELISA is positive. The EIA (enzyme immunosorbent assay) or ELISA (enzyme-linked
immunosorbent assay) is used to identify antibodies directed specifically against HIV. Target amplification methods quantify HIV RNA or DNA levels in the
plasma. Target amplification methods include reverse transcriptase polymerase chain reaction (RT-PCR). Viral Load test measures plasma HIV RNA levels.
These tests are used to track viral load and response to treatment for HIV infection.
12. ANSWER: C- Prophylactic antibiotics are given to patients with B-cell deficiency especially if they develop respiratory infections. Patients with B-cell
deficiency do not suffer from shock or fluid volume loss. Blood transfusion with whole blood is not necessary. Patients with B-cell deficiency lack plasma cells
that produce antibodies or has a diminished antibody production due to undifferentiated B-cells. Replacement therapy of immunoglobulins intravenously is
NURSING PRACTICE 4
1. ANSWER: C- The patient receives a low-residue diet to prevent frequent bowel movements that may dislodge the implant. Option A is incorrect; while
instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so that this
would not be appropriate for all clients. Option B is incorrect; surgery and radiation therapy for cervical cancer often result in shortening of the vagina, vaginal
dryness, and loss of libido due to emotional issues related to sexuality and femininity. The client’s feelings about sexuality and the partner’s feelings should
be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls.
However, this should not be the priority. Option D is incorrect; the nurse needs to explain that during the treatment, the patient must stay on absolute bed
rest. She may move from side to side with her back supported by a pillow, and the head of the bed may be raised to 15 degrees. Daily monitoring of weight
may require the client to stand up and ambulate.
2. ANSWER: C- Option C is correct; Precautions must be taken as all body secretions from the client is considered radioactive.People who are pregnant should
not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. Option A and D are incorrect;
patient should be placed bed rest with limited activity and in low residue diet to avoid possible dislodge of the implant.
3. ANSWER: B- Survival rates after lumpectomy are equivalent to those after mastectomy. Option A is incorrect; the fear and anxiety experienced by clients
varies according to their perception, beliefs, prognosis, and treatment. A client undergoing mastectomy may have the same anxiety level as a client
undergoing lumpectomy. Option C is incorrect; lumpectomy has a higher risk for local recurrence and the post-operative management is similar as anyone
having breast surgery. Option D is incorrect; because the skinhas been irradiated, the choices for reconstruction remain limited,and the woman should be
informed of this possibility at thetime of diagnosis and when considering her treatment options.
4. ANSWER: D- Early menstruation, before the age of 12, is a risk factor for breast cancer. Options A, B, and C are incorrect; use of foam contraceptives is not
a factor. Late menopause increases the risk for breast cancer, but not early menopause. A first birth at age of 30 is a risk factor, but first birth before age of 20
is not.
5. ANSWER: D- Lymph and blood are key mechanisms by which cancer cells spread. The most common mechanism of metastasis is lymphatic spread, which
is transport of tumor cells through the lymphatic circulation. Cancer cells can also spread through dissemination into the blood stream. Angiogenesis is the
mechanism by which the tumor cells are ensured a blood supply. Through this process, the malignant cells meet their needs for nutrients and capillaries.
6. ANSWER: B- Irrigations regulate the bowel to function at a specific time for the convenience of the client.
7. ANSWER: D- This is an open-ended response that encourages futher on an area that the nurse, not the client, feels is the problem.
8. ANSWER: B- The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma is usually raised beyond the skin
surface.
9. ANSWER: C- Reflection conveys acceptance and encourages further communication.
10. ANSWER: D- Removes microorganisms and irritants, protects the skin, and maintains skin integrity.
11. ANSWER: A- Cigarette smoking is the number one cause of bladder cancer. Answer B is incorrect because it is not associated with bladder cancer.
Answer C is a primary cause of gastric cancer, and answer D is a cause of certain types of lung cancer.
12. ANSWER: A- Iridium seeds can be expelled during urinary, so the client should be taught to strain his urine and report to the doctor if any of the seeds are
expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answer B, C, and D are incorrect.
13. ANSWER: B- Stage III means that cancer cells have spread into the outer layer of tissue surrounding the bladder and may have spread to surrounding
structures, but it has not spread to lymph nodes or metastasized. Tumors that have infiltrated surrounding tissues require a radical cystectomy-removal of the
bladder-and other adjacent structures. A urinary diversion must be created. One frequently used method involves using a segment of ileum to construct a
pouch that opens at the skin surface on the abdomen. This is called an ileal conduit.
14. ANSWER: D- The first sign of cancer of the bladder is frequently painless, intermittent hematuria.
15. ANSWER: C. Cold packs over the area of a dry reaction to radiation therapy are contraindicated because they reduce capillary circulation to the site and
hamper healing. Lubrication, cleansers, and cotton garments aren’t unconditionally contraindicated.
16. ANSWER: B- Knowing what to expect decreases anxiety.
17. ANSWER: D- The hallmark symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the
tumor without residual neurological damage. Before surgery, the child’s head will be shaved, although every effort is made to shave only as much hair as
necessary. Although chemotherapy may be needed, it is not the treatment of choice.
18. ANSWER: D- An acoustic neuroma tumor is one of the eighth cranial nerve that deals with balance, hearing, and coordination, making the client at risk for
injury from falls. Answers A, B, and C are appropriate priorities with the information given.
19. ANSWER: C- The patient developed hives when eating shrimp, the nurse must make a notation of allergy to shellfish because this means that contrast may
be contraindicated. At the very least, it will require more in-depth questioning on the part of the nurse or physician to determine if there is an absolute
contraindication to contrast or whether it may be safe to administer contrast following premedication with an IV antihistamine such as Benadryl.
20. ANSWER: C - An MRI is noninvasive diagnostic test that visualizes the body’s tissues, structure, and blood flow. The client is positioned on a paddle table
and move into a cylinder-shaped scanner. Relaxation techniques or a sedative are used before the procedure to reduce claustrophobic effects. There is no
useful purpose for administering an antihistamine, corticosteroid, or antibiotic.
21. ANSWER: B- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires two point of objective identification. For a client with an
armband, it is recommended that the nurse check the chart against the name and the hospital number on the client`s armband. Option A and C: in the
hospital environment the client should not participate in his identification. Option D should have been done to verify the correct order, not the client`s identity.
22. ANSWER: B- Abnormal skin pigmentation, erythema, and desquamation may develop after the radiation treatment.
23. ANSWER: C- A general body or system effect is fatigue, because it occurs as a result of changes in cell cycle patterns and toxic effects from cell
destruction. The other problems occur when radiation is directed as specific parts of the body.
24. ANSWER: C- The statistics support that infection is the most common cause of morbidity in the client with cancer. Good hand washing, monitoring with
blood cell counts, checking temperatures (watching for elevations), and when needed protective isolation (when client is severely immunosuppressed) are
the primary measures to prevent infection.
25. ANSWER: B- Radiodermatitis occurs 3 to 6 weeks after the start of treatment.
NURSING PRACTICE 5
1. ANSWER: C- Hips and knees- Degenerative joint disease is known as the “wear and tear” consequences of joint use. Weight-bearing joints are most
commonly affected by degenerative joint disease.
2. ANSWER: A- Obesity- Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease.
3. ANSWER: B- The hip shows subluxation- Partial joint dislocation or subluxation is an indication of progressive disease in which the repair processes
stimulated by the continuing damage are unable to keep pace with the rapid degeneration. Severely damaged joints do not keep the proximal and distal
bones in anatomic alignment.
4. ANSWER: C - Swimming 3 times per week- Exercising on a regular basis is important; however, the exercise should not put more stress on the diseased
joint. Thus, weight-bearing exercises must be engaged in cautiously. Swimming allows the movement of all joints with less stress because the force of gravity
on the joint is greatly reduced. No diet has been found effective in slowing disease progression. Aspirin may held reduce discomfort and, if inflammation is
present, may help reduce inflammation (although an aspirin daily is not a therapeutic dose), but does not prevent complications or slow progression.
5. ANSWER: D- Sulfa drugs- Many clients with an allergy to sulfa drugs have a cross-reactivity with celecoxib. This drug should be avoided in clients who have
a known allergy to sulfa drugs in order to prevent a serious allergic reaction or anaphylaxis.
6. ANSWER: D - Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does
not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree
of flexion.
7. ANSWER: B - Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal
compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.
8. ANSWER: D - Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an
adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving
gentamicin by any route should have kidney function monitored.
9. ANSWER: C - Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to
the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb.
This problem can be reduced or corrected with an escharotomy.
10. ANSWER: C - Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and
decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
11. ANSWER: D. - The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening. A-
The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. B- A cut hand is priority, but not over a
client having a myocardial infarction. C- These are symptoms of a migraine headache and are not life threatening.
12. ANSWER: D- A post-incident response is important to include a critique and debriefing for all parties involved; a pre-incident response is the plan itself. Be
sure to read adjectives closely. A- Practice drills allow for troubleshooting any issues before a real-life-incident occurs. B- A deactivation response is
important so that resources are not overused, and the facility can then get back to daily activities and routine care. C- A coordinated security plan involving
facility and community agencies is the key to controlling an otherwise chaotic situation.
13. ANSWER: B- This client has a very poor prognosis, and even with treatment, survival is unlikely. A- This client would be an Immediate Category, Priority 1,
and color red. If not treated STAT, a tension pneumothorax will occur. C- This client would be a Delayed Category, Priority 2, and color yellow. This client
would receive treatment after casualties requiring immediate treatment are treated. D- This client would be a Minimal Category, Priority 3, and color green.
This client can wait days for treatment.