This action might not be possible to undo. Are you sure you want to continue?
" The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help. 1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is: a. help the client find meaning in his experience b. help the client to plan alternatives c. help the client cope with present problem d. help the client to communicate 2. The nurse is guided that Jimmy is aware of his concerns of the "here and now" when he crossed out which item from this "list of what to know" a. anxiety laden unconscious conflicts b. subjective idea of the range of mild to severe anxiety c. early signs of anxiety d. physiological indices of anxiety 3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete disruption of the ability to perceive occurs in: a. panic state of anxiety b. severe anxiety c. moderate anxiety d. mild anxiety 4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT: a. agreeing to contact the staff when he is anxious b. becoming aware of the conscious feeling c. assessing need for medication and medicating himself d. writing out a list of behaviors that he identifies as anxious 5. The nurse notes effectiveness of Interventions in using subjective and objective data in the: a. initial plans or order b. database c. problem list
d. progress notes Situation 2 - A research study was under taken in order to identify and analyze a disabled boy's coping reaction pattern during stress. 6. This study which is a depth study of one boy is a: a. case study b. longitudinal study c. cross-sectional study d. evaluative study 7. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process recording? a. Non verbal narrative account b. Audio and interpretation c. Audio-visual recording d. Verbal narrative account 8. Which of these does NOT happen in a descriptive study? a. Exploration of relationship between two or more phenomena b. Exploration of relationships between two or more phenomena c. Manipulation of phenomenon in real life context d. Manipulation of a variable 9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an. a. Participant-observer b. Observer researcher c. Caregiver d. Advocate 10. To ensure reliability of the study, the investigator analysis and interpretations were: a. subjected to statistical treatment b. correlated with a list coping behaviors c. subjected to an inter-observe agreement d scored and compared standard criteria Situation 3 - During the morning endorsement, the' outgoing nurse informed the
nursing staff that Regina, 5 years old, was given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night nurse. 11. Which of the following approaches of the nurse validates the data gathered? a. "I learned that you were up till ten last night, tell me what happened before you were finally able to sleep and how was your sleep?" b. "Hmm...You look like you had a very sound sleep. That pill you were given last night is effective isn't it?" c. "Regina, did you sleep we!!?" d. "Regina, how are you?" 12. Regina is a high school teacher. Which of these information LE^ST communicate attention and care for her needs for information about her medicine? a. Guided by a medication teaching plan go over with her the purpose, indications and special instructions, about the medication and provide her a checklist b. Provide a drug literature c. Have an informal conversation about the medication and its effects d. Ask her what time she would like to watch the informative video about the medication 13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to a. face emerging problems realistically b. conceptualize her problem c. cope with her present problem d. perceive her participation in an experience 14. Which of these responses indicate that Regina needs further discussion regarding special instructions? a. "I have to take this medicine judiciously." b. "I know 1 will stop taking the medicine when there is an advice form the doctor for me to discontinue." c. "I will inform you and the doctor any untoward reactions I have." d. "I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life." 15. Regina commits to herself that she understood and will observe all the
Communicating ambivalent messages to the client 20. Responding in a punitive manner to the client b. validation d. Human beings are systems of interdependent and interrelated parts c. The nurse's most unique tool in working with the emotionally ill client is his/her: a. collaboration 19. The rnentally ill person responds positively to the nurse who is warm and . a. Rejecting the client as a unique human being c. verbally agreeing with the nurse d. All of the following response are non therapeutic. One way to increase objectivity in dealing with one¶s fears and anxieties is through the process of: a. committing what she learned to her memory c. intervention c. 16. relying on her husband to remember the precautions Situation 4 .medicine precautions by. There is a basic similarity among all human beings 18. Each individual has the potential for growth and change in the direction of positive mental health d. theoretical knowledge b. Which is the MOST direct violation of the concept. affixing her signature to the teaching plan that she has understood the nurse b. Tolerating all behavior in the client d.The nurse-patient relationship is a modality through which the nurse meets the client's needs. personality make up c. communicating a message or a need b. congruence of behavior? a. emotional reactions d. All behavior is meaningful. communication skills 17. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that states: a. observation b.
" ." d. "Yes. This demonstration of the nurse¶s role as: a. it is against hospital policy. "Yes." b. you have the right to invoke confidentiality of our interaction. 21. "I am sorry. this is just between you and me. our interaction is confidential provided the information you tell me is not detrimental to your safety." c." b. mother surrogate c. Rapport has been established in the nurse-client interaction time. Promise!" c. The client says. though I would want to. towards the end of the relationship d. "Yes. if you keep it confidential. a secret?" A therapeutic response of the nurse is: a. socializing agent Situation 5 . loyalty c. this is part of privileged communication. I am committed to have this time available for us while you are at the hospital and ends after your discharge. it is my principle to uphold my client's rights. "I want to tell you something but can you promise that you will keep this. trustworthiness b. "Yes." 23.The nurse engages the client in a. when the client asks. how long one relationship would be b. therapist d. I am committed to have this time available for us while you are at the hospital and ends after your discharge. "Of course yes. "The best time to talk is during the nurse-client interaction time." d. When the nurse respects the client's self-disclosure. The best time to inform the client about terminating the nurse-patient relationship is a." a. counselor b.caring. this is a gauge for the nurse's: a. integrity d. at the start of the relationship 22. nurse-patient interaction. during the working phase c. professionalism 24. "I am committed for your care.
Narcissistic behavior . "Here (gives her mobile phone). Camila refuses to relate with others because she: a. to the development of schizophrenia? a. 25 years old. Inform the attending psychiatric about the request of the client b. Ask the client what is the purpose of contacting his relatives Situation 6 .Camila.25. Ambivalence c. telephone number and requests the nurse to call. Extreme rebellion towards authority figures d. She became neglectful of her personal hygiene. He gives a. is irritable b. anticipates rejection d. schizoid b. She was observed to be talking irrelevantly and incoherently. ambivert d. She was diagnosed as schizophrenia 26. Faulty family atmosphere and interaction c. You may call this number now. Guilt feelings b. is depressed 28." d. Solo parenting 29. The past history of Camila would most probably reveal that her premorbid personality is: a. Which of the following disturbances in interpersonal relationships MOST often predispose. Lack of participation in peer groups b. An appropriate action of the nurse would be: a. cycloid 27. was reported to be gradually withdrawing and isolating herself from friends and family members. Assist the client to bring his concern to the attention of the social worker c. Camila's indifference toward the environment is a compensatory behavior to overcome: a. feels superior of others c. The client has not been visited by relatives for months. extrovert c.
Using short simple sentences b.Salome. She would prefer to be alone and take her meals by herself. the Geriatic clinic for assessment and treatment. social isolation c. anxiety disorder b. attempt to maintain authoritative role c. A nursing diagnosis for Salome is: a. accept the steady loss of hearing that occurs with aging d.perceptual function b. ego despair 33. Speaking distinctly and slowly c. 31. cognitive impairment d. increase her self-esteem to maintain her authoritative role 34. Speaking at eye level and having the client's attention d. Allowing her to take her meals alone . The daughter understood. demanding and speaking louder than usual. has been observed to be irritable. adjust to the loss of sensory and . the following ways to assist Salome meet her needs and avoiding which of the following: a. Schizophrenia is a/an: a. 80 year old widow. psychosis d. beginning indifference to the world around her b. neurosis c. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become aggressive is a/an: a. The nurse will assist Salome and her daughter to plan a goal which is: a. behavior indicative of unresolved repressed conflict of the part 32. overcompensation for hearing loss d. participate in conversation and other social situations c. sensory deprivation b.d. minimized receiving visitors al home and no longer bothers to answer telephone calls because of deterioration of her hearing. 'She was brought by her daughter to. Insecurity feelings 30. personality/disorder Situation 7 .
the device is turned on and adjusted to a: a. cognition c. neurotic 38. She understood the proper . psychotic d. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her. psychosomatic c. organic b. Cecilia is demonstrating: a. agoraphobia d. Cecilia is persistently feeling restless. comfortable level c. Which of the following should the nurse implement? a. 36. and thoughts b. Salome was fitted a hearing aid. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. audible level Situation 8 .use and wear of this device when she ways that the battery should be functional. observation d. assist her in recognizing irrational beliefs. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her: a. perception 39. help find meaning in her behavior c. Cecilia's problem is that she always sees and thinks negative hence she is always fearful Phobia is a symptom described as: a. therapeutic level b.For more than a month now.35. prescribed level d. xenophobia 37. acrophobia b. provide positive reinforcement for acceptable behavior . communication b. claustrophobia c. worried and feeling as if something dreadful is going to happen.
administer anxiolytic drug 40.it is the first day of clinical experience of nursing students at the Psychiatry Ward. After discharge. Parents or legal guardian d.Plan) statements on a problem: Anxiety about diagnosis. she joint an art therapy group Situation 9 . Relate patient's feelings to physician initiate and encourage her to verbalize her fears . What is the objective data? a. The nurse must see to it that the written consent of mentally ill patients must be taken from: a. Doctor b.During the orientation. Law enforcement authorities 43. she watches television with the family in the recreation room d. 41. which of these behaviors indicate a positive result of being able to overcome her phobia? a. Informed consent b. the order has to be correctly written and signed by the physician within. 36 hours c. the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient's records from loss or destruction or from people not authorized to bead it. 48 hours d. 24 hours b. In an extreme situation and when no other resident or intern is available. she drives alone along the long expressway c. 12 hours 44.Analysis .d. telephone orders. she read a book in the public library b. It is unethical to tell one's friends and family member¶s data bout patients because doing so is violation of patients¶ rights to: a.Objective . The following are SOAP (Subjective . Confidentiality c. a. Civil liberty 42. should a nurse receive. Social worker c. Least restrictive environment d.
Anxiety due to the unknown d.give emotional support by spending more time with patient. EXCEPT one comprise the concepts of behavior therapy program: a. "I¶m so worried about what else they'll find wrong with me" 45. be lowing yet firm 49. learning d. reward and punishment b. Patient's responses to health: and illness as a total person in interaction with the environment d. it is important for the parents to be consistent with the following approaches EXCEPT: a discipline with a king attitude b matter of fact in handling the behavior c. Identification of patient's responses to medical diagnosis and treatment c. A therapeutic verbal approach that communicates strong disapproval is: . frequently verbalizes fear of what diagnostic tests will reveal c. Step procedures for the management of common problems Situation 10 . Which of the following is the MOST common physiological cause of night bedwetting? a.Marie is 5 ½ years old and described by the mother as bedwetting at night. abnormal bladder development or structure problems c. infections familial and genetic factors 47. sympathize for the child d. The help Marie who bed wets at night practice acceptable and appropriate behavior. b. Summary of chronological notations made by individuals health team members b. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the: a. placebo as a form treatment 48. continue to make necessary explanations regarding diagnostic test. Has periods of crying. All of the following. deep sleep factors b. 46. extinction c.
a. To call for help from the other members of the team d. Hands by sides but palms turned outwards 52. I'd be upset and disappointed. e. To stay and fight or run away 53. Situation 11 . To remain and cope with the incident b. "When asked about his relationship with his father. 51.a. fold his/her arms across his/her chest c." b. "If you don't make an effort to control your bedwetting. You are supposed to get up and go in the toilet when you feel you have to go and did not." b. Which of the following is an accurate way of reporting and recording an incident? a. Tokens make her materialistic at an early age. The next time you bed wet. "When asked about his relationship with his father. the nurse should: a." c. "If you bed wet. keep his/her hands behind his/her back or in one's pocket c. client became anxious. I¶ll tell your friends and hand your sheets out the window for them to see.g. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual. keep an eye contact while staring at the client b. you will change your bed linen and wash the sheets. Promise him/her a long awaited vacation after school is over. client clenched his jaw/teeth . During your conference. What does you child want that you can give every time he/she wakes up dray in the morning d. I expect you to from now on without fail. keep an "open" posture. "You are supposed to get up and go in the toilet when you feel you have to go and you did not." 50. the parent inquires how to motivate Marie to be dry in the morning. give a prize b. During the pre-interaction phase of the N-P relationship/the nurse recognizes this normal INITIAL reaction to an assaultive or potentially assaultive person. Your response which is an immediate intervention would be: a.The nurse is often met with t-he following situations when clients become angry and hostile. Display empathy towards the patient c. Give praise and hugs occasionally c. Give a star each time she wakes up dry and every set of five stars." d.
"When asked about his relationship with his father. ineffective coping d. The nurse best responds saying. Suspicion c. In planning care for a patient with Parkinson's disease. Ability to avoid interpersonal conflict c. "Calm down. "When asked about his relationship with his father." c." b. "How do you usually express anger?" d. A healthy adaptation to aging is primarily related to an individual. client was resistant to respond.Nursing care for the elderly." d." d. Physical health throughout life d. which of these nursing diagnoses should have priority? a. a. a." Situation 12 . 56. "When do you usually feel angry?" c. "What situations provoke you to be angry?" 55. To encourage thought. Which of the following approaches is NOT therapeutic? a. altered mood state 57." c. potential for injury b. Loneliness b. altered nutritional state c. Grief d. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of the following responses to old age? a. "Why do you feel angry?" b. "Stop! Put that chair down. A patient grabs a chair and about to throw it. Number of accomplishments b. "Don't be silly." 54. his anger was suppressed. Confusion . "Stop. the security will be here in a minute.made a fist and turned away from the nurse. Personality development in his life span 58.
Crisis b. Leave a light on all night c. Remind client to call the nurse when she wants to get up d.59. unhappy and miserable1 is experiencing: a. put side rails on the bed 60. Assign client to a single room b. Ambivalence Situation 13 . The traction ropes move freely through the pulley 62. Graciela's buttocks are resting on the bed b. 61. While on Bryant's traction. Graciela is assessed to have no head injury. Vomiting c. A positive Kernig's sign 63. The Bryant's traction is removed. She will be observed for signs of increased intracranial pressure which include: a. An elderly who has lots of regrets. Despair c. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she returns. Narrowing of the pulse pressure b. Which of these finding as a concern of immediate attention that must be reported to the physician immediately? . The nurse notes that the fall might also cause a possible head injury. Periorbital edema d. Loss d.Graciela 1 ½ year old is admitted the hospital from the emergency room with a fracture of the left femur due to a Tall down a flight of stairs. A plaster of Paris his spica is applied. which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction? a. Graciela is placed oh Bryant's traction. The MOST appropriate action the nurse would take is to: a. The traction weights are hanging 10 inches above the floor c. Graciela's legs are suspended at a 90 degree angle to her trunk d.
Which of these statements indicate that the mother understood an important aspect of case care? a.Jolina is an 18 year old beginning college student. She has lost insight. Graciela is scratching the cast over her abdomen b. 66. Trust b. Industry d. I will place plastic sheeting around the perineal area of the cast c.a. psychotic depression 67. I will use white shoe polish to keep the cast neat b. Setraline (Zoloft) b. The nurse counsels Graciela's mother ways to safeguard safety white providing opportunities of Graciela to develop a sense of: a. Initiative c. I will reinforce cracked areas on the cast with adhesive tape 65. lost interest in anything and complained and complained of constant tiredness. Her mother observed that she is having problems relating with her friends. exogenous depression b. Jolina still manifests . I will use cool water to wash the cast d. The toes of Graciela's left foot blanch when the nurse applies pressure on them c. These drugs act on the brain chemistry. This is a tricyclic antidepressant drug: a. Graciela's cast is still damp d. Imipramine (Tofranil) 68. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother. Jolina is out on antidepressant drugs. The nurse is unable to insert a finger under the edge of Graciela's cast on her left foot 64. After one week of antidepressant medication. neurotic depression c. Venlafaxine (Effexor) c. therefore they would be useful in which type of depression? a. Autonomy Situation 14 . She is undecided about her future. endogenous depression d. Flouxetine (Prozac) d.
Ineffective result because perhaps the drug's dosage is inadequate 69. a. Encourage her to join group therapy with other patients 70. Encourage her to join socialization hour so she will start to relate with others d. Expected because therapeutic effectiveness takes 2-4 weeks d. The goal of remotivation therapy is to facilitate: a. Unexpected because therapeutic effectiveness takes within a few days c. What were you saying? b.depression.Group Approach" in Nursing. Formulate a structured schedule so she is able to channel her energies externally b. During the predischarge conference. Insight b. Unusual because action of antidepressant drug is immediate b. Why haven't we heard from you? 73. Realistically assess her assets and limitations d Solve her own problems Situation 15 . Jolina continues to verbalize feeling sad and hopeless. the nurse suggests vocational guidance because it should help Jolina to: a. Discovers that his feelings are shared by the group members c. She is not mixing well with other clients. Which of the following questions illustrates the group role of encourager? a. Discusses personal concerns with group members 72. The nurse evaluates this as. Let her alone until she feels like mingling with others c. Where do you go from here? d. Make some decision about her future c. Productivity . 71. Who wants to respond next? c. Find a good job b. Accomplishes his goal in joining the group b. One of the nurse's important consideration for Jolina Initially is to: a. Membership dropout generally occurs in group therapy after a member: a. Experiences feelings of frustration in the group d.
c. free clinics and more hospitals 77. treatment b. is "contaminated" by the presence of deviant member and all members need treatment 75. The treatment of the family as a unit is based on the belief that the family: a. social action d. Lorelle upon discharge was referred to a volunteer group where she has learned to read patterns. A community approach to cope with this problem is for the nurse to support: a. Intimacy 74. Caution b. Cohesiveness c. The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of: a. 76. cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future. Poverty as reflected in prevalence of communicable diseases. is a social system and all the members are interrelated components of that system b. Socialization d.The mental health . as a unit of society needs the opportunity to change its own destiny c. provision of social welfare benefits for the poor c. aggressive family planning methods b.psychiatric nurse functions in a variety of setting with different types of clients. homeless and prostitution is a predisposing factor to mental illness. Confusion d. rehabilitation d. The working phase in therapy group is usually characterized by which of the following? a. prevention c. research 78. who has therapy together will tend to remain together d. Competition Situation 16 . malnutrition and social ills such as street children. What type of activity therapy is this? .
Child abuse c. Educational therapy 79. due to biochemical factors 82. In a residential treatment home for adolescent girl's the clients were becoming increasingly tense and upset because of shortening of their recreation time. 81. a common problem brought about by socioeconomic deprivation b. Recreational therapy b. Drug education b. religious music b. Which of these topics would the school nurse consider as priority for their parents¶ class? a. conscience b. dance music d.a. super ego . rock music 80. caused by multiplicity of factors c. Being in contact with reality and the environment is a function of the: a. Effective parenting d. relaxation music c. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses d. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is: a. To die escalate possible anger and aggression among the clients it is BEST to play: a. ego c. Vocational therapy d. Sex education Situation 17 . Art therapy c.Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. The parents of special children who are behaviorally disturbed need mental health education. id d.
implement behavior modification d. No to your request. Commonly known as "shabu" is: a. produces less severe symptoms than that of abuse d. Cannabis Sativa b. it is a priority for the nurse to: a. During the detoxification stage. "If I say. increase the client's awareness of unsatisfactory protective behaviors c.It is common that client ask the nurse personal questions. methamphetamine d. what are your thoughts about it?´ d. Termination phase 87. 86. Lysergic add diethylamide c. The client asks for the nurse's telephone number. includes characteristics of tolerance and withdrawal 84. requires long term treatment in a hospital based program c. substance dependence: a. Orientation phase b. Methylenedioxy. When the client asks about the family of the nurse the MOST appropriate response is: a. Methamphetamine hydrochloride Situation 18 .83. Substance abuse is different from substance dependence is than. Pre-interaction phase d. promote homeostasis and minimize the client¶s withdrawal symptoms 85. includes characteristics of adverse consequences and repeated use b. teach skills to recognize and respond to health threatening situations b. "Are you asking for an official number of the hospital/clinic for your reference?" 88. which of these responses is NOT appropriate? a." b. "What would you do with my number if I give it to you?" c. "it is confidential I just don't give it to anyone. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? a. Avoid the situation and redirect the client's attention . Working phase c.
Need for self-esteem c. He stands 5' ½" and weight 100 lbs. what time is it?" Situation 19 . Introduce another topic like the client's interests 89.Ricky is a 12 year old-boy with Down¶s syndrome. classroom.ray of cervical spine showed "subluxation of CI in relation to C2 with cord compression." c. When the nurse is asked a personal question. The client knows no other way to begin a conversation d. "Why do you ask?" d. The classroom teacher consults the school for guidance on how to take care of Ricky while inside the. Divert Ricky's attention and engage him in satisfying activities b. The nurse has one on one health education sessions with Ricky's mother. "What time is it?" The nurse's appropriate response is: a. The client is simply curious b. which of these reactions indicate a need her to introspect? a. X . Give a brief and simple response and focus on the client c. Needs for safety and Security d. " What should I do when Ricky fond his genitalia?" Appropriate response of the nurse is for the mother to: a. "It is 10 o¶clock. 91. "Why don't we talk about your family instead?" d. His/her right to privacy is being intruded c. He is slim and walks sluggishly with a limp. She asked. Ignore Ricky's behavior because he will outgrow it later d. . Physiological needs b. It is 10 o'clock of your watch. "Are you bored?" b. The client asks. "Guess. Tell Ricky that it is wrong to keep fondling his genitalia c. Ricky's: a. Needs for belonging 92.b. Engage him in computer TV games that engage his hands 93. The nurse considers as priority. He wears a neck brace as support for his neck. Some patients are like children in seeking recognition from the nurse 90." He attends a school for special education. Ricky's mother visited the school nurse.
church d.The abuse of dangerous drug is a serious public health concern that nurses need to address. fantasies. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the: a. Working with clay b. Profit from vocational training with moderate supervision b. she should constantly provide activities for Ricky to be able to: a. Preparing and cooking simple menu d. family 97. distortion of size. sublimation 98. socialize with people b. loss of train of thought. All of the following activities are appropriate for Ricky EXCEPT: a. and "bloodshot eyes". due to . 96. Ricky's IQ falls within the range of 50-55. Perform simple tasks in closely supervised settings d. Card and table games 95. Competitive sports c. This drug produces mirthfulness. school c. projection d. a. Live successfully in the community c. eventually go to school alone c. select and prepare his own food d. He can be expected to: a. distance and time. rationalization c. level Situation 20 .The mother understood that for her son to learn to cope and be independent. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain. law enforcement agencies b. repression b. flight of ideas. Acquire academic skills of 6th grade. do activities of daily living 94.
Codependent c. Sudden death from cardiac or respiratory depression b. Supportive ANSWER KEY: 1. The mother's behavior can be described as: a. a.her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse. D 15. Psychological dependence after prolonged use 100. C 3. C 8. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just becomes worse while relating with other drugs users. A 7. Danger of acquiring hepatitis or AIDS c. Opiates b. D 14. A 16. LSD c. Caretaking d. Marijuana d. A 12. Heroin 99. D 10. C 2.dilated pupils. Experience of "blackout" d. D 13. Unhelpful b. B 4. a. D 9. A 11. The nurse evaluates that-. D 6. D . A 5.
27. 57. 40. 48. 21. 28. 38. 55. 42. 53. 26. 29. 19. 52. 25. 60. 58. 46. 37. C B A A A B C C A A A D D C D B A A B C A B C D B B A A A C D A B . 44. 35. 31. 41. 24. 49. 50. 22. 56. 34. 47. 43. 51. 32. 18. 36. 30.17. 59. 45. 54. 33. 20. 23. 39.
D 97. C 92. B 77. B 78. B 83. D 64. A . B 82.61. B 91. A 88. D 85. A 62. C 96. A 98. D 66. D 90. D 65. C 71. D 86. 93. B 95. C 72. D 84. B 80. B 73. C 69. C 70. C 79. A 100. B 76. B 87. C 81. A 75. D 94. B 89. B 74. D 68. B 67. B 99. B 63.
B. 2.´ Answer: (C) ³With a pillow. Following surgery. The nurse¶s best response would be: A. The nurse needs to carefully assess the complaint of pain of the elderly because older people A. ³This is a normal reaction after surgery. B. The patient is anxious about upcoming surgery Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate. than before the medication was administered. ³I will give you the pain medication the physician ordered. Mario complains of mild incisional pain while performing deepbreathing and coughing exercises.´ C.´ Applying pressure against the incision with a pillow will help lessen the intraabdominal pressure created by coughing which causes tension on the incision that leads to pain. The response to pain in the elderly maybe lessened because of reduced acuity of touch. Suspecting shock. Ana¶s postoperative vital signs are a blood pressure of 80/50 mm Hg. The patient is having an allergic reaction to the drug.´ B. . and respirations of 32. ³With a pillow.´ D. 4. Administer oxygen at 100%. This is normal side-effect of AtSO4 D. have altered mental function Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly. are expected to experience chronic pain B.1. apply pressure against the incision. alterations in neural pathways and diminished processing of sensory data. have a decreased pain threshold C. experience reduced sensory perception D. The patient needs a higher dose of this drug C. a pulse of 140. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher. 3. The nurse¶s best A. apply pressure against the incision. Put the client in modified Trendelenberg's position. which of the following orders would the nurse question? A. ³Pain will become less each day.
C. How are you feeling about tomorrow's surgery?" Answer: (D) "Mr. you appear anxious to me. Wasn't it a pleasant day. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Pablo. Mr. ³Mr. Perez is in continuous pain from cancer that has metastasized to the bone. He is wringing his hands and pacing the floor when the nurse enters his room. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention. . "Mr. 7. All the other interventions can be expected to be done by the nurse. What is needed is promotion for adequate oxygenation and perfusion. Administer Demerol 50mg IM q4h Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol.C. She continues to complain of nausea. Recognizing the client¶s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns. I'll leave you alone with your thoughts. Insertion of the NGT helps relieve the problem. diagnosed with Bladder Cancer. B. D. C. Mr. 6. Nausea is one of the common complaints of a patient after receiving general anesthesia. today?" B. Change the patient¶s position. "Mr. you appear anxious to me. Pablo." D. Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. Check the patency of the nasogastric tube for any obstruction. you'll wear out the hospital floors and yourself at this rate. Pablo. which is a narcotic analgesic. Pablo. After surgery. Administer the prescribed antiemetic. is scheduled for a cystectomy with the creation of an ileal conduit in the morning. Pablo. Pablo. Call the physician immediately. "Good evening. Which action would the nurse take? A. Answer: (C) Check the patency of the nasogastric tube for any obstruction. Monitor urine output every hour. D. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. What is the best approach? A. Mr. you must be so worried. can depress respiratory and cardiac function and thus not given to a patient in shock. 5.
Bleeding from ears D. the patient needs to be supported and handled gently. Handle him gently when assisting with required care D. Let him perform his own activities of daily living C. A depressed fontanel C. Take his vital signs again in an hour. and respirations are 24. Answer: (B) Take his vital signs again in 15 minutes. D. During nursing care. His pulse is 82.Pain medication provides little relief and he refuses to move. Monitoring the client¶s vital signs following surgery gives the nurse a sound information about the client¶s condition. Complete A. his pulse rate is 94. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. An elevated temperature Answer: (C) Bleeding from ears The nurse needs to perform a thorough assessment that could indicate . The nurse should plan to: A. B. Notify his physician. A client returns from the recovery room at 9AM alert and oriented. What nursing action is most appropriate? A. Reactive pupils B. When assessing the client. however. Place the patient in shock position. At 10 am and at 11 am. C. At noon. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. with an IV infusing. respirations are 20. Take his vital signs again in 15 minutes. 8. the nurse would be most concerned if the assessment revealed: A. Complications can occur during this period as a result of the surgery or the anesthesia or both. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. his vital signs are stable. care quickly as possible when necessary Answer: (C) Handle him gently when assisting with required care Patients with cancer and bone metastasis experience severe pain especially when moving.M. Reassure him that the nurses will not hurt him B. and all are within normal range. blood pressure is 120/80. 9. blood pressure is 116/74.
Which of the following activities will not stimulate Valsalva's maneuver? A. statements by the client to the nurse indicates a risk factor for CAD? A. .alterations in cerebral function. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.´ Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Do not give the drug if the apical rate is less than 60 beats per minute. Use of stool softeners.´ Answer: (D) ³I smoke 1 1/2 packs of cigarettes per day. Which of the ff. Gagging while toothbrushing. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation 10. 11. Exercise and maintaining normal serum cholesterol levels help in its prevention. liver and renal problems D. This increases cardiac output that improves renal perfusion resulting in an improved urine output. Enema administration C. ³I exercise every other day. It has positive inotropic and negative chronotropic effects B.´ D.25 mg. increased intracranial pressures.´ C. D. Valsalva maneuver can result in bradycardia.´ B. ³My father died of Myasthenia Gravis. fractures and bleeding. Toxixity can occur more easily in the presence of hypokalemia. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. ³I smoke 1 1/2 packs of cigarettes per day. ³My cholesterol is 180. Braga was ordered Digoxin 0. Mr. Answer: (B) The positive inotropic effect will decrease urine output Inotropic effect of drugs on the heart causes increase force of its contraction. The positive inotropic effect will decrease urine output C. B. Lifting heavy objects Answer: (A) Use of stool softeners. 12. OD. Which is poor knowledge regarding this drug? A.
may engage in contact sports Answer: (D) may engage in contact sports The client should be advised by the nurse to avoid contact sports. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 ± 5 mins. may be allowed to use electrical appliances C. If the pain continues. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. If the pain is not relieved in 15 minutes. then go lie down. If the chest pain is unrelieved. This will prevent trauma to the area of the pacemaker generator. Answer: (D) ³Place one Nitroglycerine tablet under the tongue every five minutes for three doses.´ B. 14. ³Place one Nitroglycerine tablet under the tongue every five minutes for three doses. in the morning upon awakening B. begin taking the nitro tablets one every 5 minutes for 15 minutes. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. The nurse is teaching the patient regarding his permanent artificial pacemaker. have regular follow up care D.13. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food? A. after three tablets. Whole milk B. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Go to the hospital if the pain is unrelieved. and place one tablet under your tongue. lie down. Which of the following instructions does the nurse include in the teaching? A. take the pulse rate once a day. and if the pain does not go away in 10 minutes. Canned sardines . take another tablet in 5 minutes.´ D. 15. ³Place one tablet under your tongue. go to the hospital. A client with chronic heart failure has been placed on a diet restricted to 2000mg. ³Continue your activity. there is a possibility of acute coronary occlusion that requires immediate medical attention. ³When your chest pain begins. Go to the hospital if the pain is unrelieved. of sodium per day.´ C.
D. Instruct the client about the need for bed rest. It interferes with vitamin K absorption. It prevents conversion of factors that are needed in the formation of clots.C. Heparin is an anticoagulant. Foamy. It inactivates thrombin that forms and dissolves existing thrombi. D. Eggs Answer: (B) Canned sardines Canned foods are generally rich in sodium content as salt is used as the main preservative. A client receiving heparin sodium asks the nurse how the drug works. Which finding would the nurse state as a common symptom of lung cancer? : A. In a client with thrombophlebitis. Provide active range-of-motion exercises to both legs at least twice every shift. B. Answer: (C) Instruct the client about the need for bed rest. It does not dissolve a clot. 17. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate? A. bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. Elevate the client's legs 90 degrees. 18. B. 16. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. It dissolves existing thrombi. C. Plain nuts D. Dyspnea on exertion B. The nurse is conducting an education session for a group of smokers in a ³stop smoking´ class. It prevents the conversion of prothrombin to thrombin. C. Wheezing sound on inspiration D. blood-tinged sputum C. Cough or change in a chronic cough Answer: (D) Cough or change in a chronic cough . Which of the following points would the nurse include in the explanation to the client? A. Apply a heating pad to the involved site.
Blood gases are monitored using a pulse oximeter. The irritation causes the cough which initially maybe dry. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. the nurse knows that the purpose of this choice of treatment is to A. Gain a more rapid systemic effect . This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. When informing the client of this decision. Suction until the client indicates to stop or no longer than 20 second D. obstruction of the airways occurs and the cough may become productive due to infection. Oxygen is administered best using a non-rebreathing mask D. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. Use sterile technique with a two-gloved approach C. Which is the most relevant knowledge about oxygen administration to a client with COPD? A. The hypoxic state of the client then becomes the stimulus for breathing. Destroy resistant organisms and promote proper blood levels of the drugs C. Suctioning sucks not only the secretions but also the gases found in the airways. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. persistent and unproductive. B. Lubricate the catheter tip with sterile saline before insertion. As the tumor enlarges. When suctioning mucus from a client's lungs. 20. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. which nursing action would be least appropriate? A. 19. C. Giving the clientoxygen in low concentrations will maintain the client¶s hypoxic drive.Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. Hyperoxygenate the client before and after suctioning Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. Dr. 21. Cause less irritation to the gastrointestinal tract B.
Inhale slowly through the mouth as the canister is pressed down C. B. Delay resistance and increase the tuberculostatic effect Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. D. 23. this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.D. A client with COPD is being prepared for discharge. Using drugs in combination can delay the drug resistance. and one-bottle water-seal drainage is instituted in the operating room. there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT A. When teaching the client what to expect afterward. Chest tubes are inserted. Increase venous return Answer: (B) Facilitate ventilation of the left lung. Breath in and out as fully as possible before placing the mouthpiece inside the mouth. Hold his breath for about 10 seconds before exhaling D. 22. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Equalize pressure in the pleural space. Since only a partial pneumonectomy is done. Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips. the nurse's highest priority of information would be . C. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. B. Facilitate ventilation of the left lung. A client is scheduled for a bronchoscopy. 24. In the postanesthesia care unit Mario is placed in Fowler's position on either his right side or on his back to A. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. Mario undergoes a left thoracotomy and a partial pneumonectomy. Reduce incisional pain.
Position the client in a Fowler's position. C. Impaired gas exchange. D. causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Coughing and deep-breathing exercises will be done q2h. The client with COPD is suffering from chronic CO2 retention. Because the patient would require adequate hydration. Which is the most appropriate nursing diagnosis for this patient? A. Decreased tissue perfusion. Fluid volume deficit B. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. The client's nasal cannula oxygen is running at a rate of 6 L per minute. 27. which is an infection. The nurse enters the room of a client with chronic obstructive pulmonary disease. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR. and the respirations are 9 per minute and shallow. this makes him prone to fluid volume excess.A. Answer: (A) Food and fluids will be withheld for at least 2 hours. 26. C. The hypoxic drive is his chief stimulus for breathing. Pneumonia. Take heart rate and blood pressure. Answer: (C) Lower the oxygen rate. 25. A nurse at the weight loss clinic assesses a client who has a large abdomen . Warm saline gargles will be done q 2h. Food and fluids will be withheld for at least 2 hours. Risk for infection Answer: (C) Impaired gas exchange. Call the physician. B. The gag reflex usually returns after two hours. Prior to bronchoscopy. the skin color is pink. Lower the oxygen rate. Only ice chips and cold liquids will be allowed initially. B. the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. D. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. C. What is the nurse¶s best initial action? A. D.
and a rounded face. ³I must take this medicine exactly as my doctor ordered it. All these are noted in a client with Cushing¶s syndrome. Blood glucose Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure. 28. I shouldn¶t skip doses. increase tendency to infection and poor wound healing.´ B. Clients on the drug must follow strictly the doctor¶s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis 29. large thighs and upper arms B. ³This medicine will protect me from getting any colds or infection.´ C. pendulous abdomen and large hips C. The nurse is attending a bridal shower for a friend when another guest. who . Blood pressure D. Hand grips C. posterior neck fat pad and thin extremities Answer: (D) posterior neck fat pad and thin extremities ³Buffalo hump´ is the accumulation of fat pads over the upper back and neck. 30. Pupil reaction B. There is truncal obesity but the extremities are thin. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy? A. abdominal striae and ankle enlargement D.´ Answer: (B) ³I must take this medicine exactly as my doctor ordered it. Fat may also accumulate on the face. ³My incision will heal much faster because of this drug.´ The possible side effects of steroid administration are hypokalemia. Which assessment is essential for the nurse to make first? A. I shouldn¶t skip doses. palpitation and headache. complains of sweating. Which additional assessment finding would lead the nurse to suspect that the client has Cushing¶s syndrome rather than obesity? A. ³I should limit my potassium intake because hyperkalemia is a side-effect of this drug. A client.´ D. who is suspected of having Pheochromocytoma.
When this occurs in a conscious client. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry .´ B. he should be given immediately carbohydrates in the form of fruit juice. During the first 24 hours after thyroid surgery. ³The medication will limit thyroid hormone secretion. glucagons or dextrose per IV.´ Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave¶s disease. honey or. starts to tremble and complains of dizziness. 32. the best response would be: A.´ D. asks the nurse. Advising the client that she can resume her normal activities immediately Answer: (A) Checking the back and sides of the operative dressing Following surgery of the thyroid gland. Encouraging the client to ventilate her feelings about the surgery D. ³Why do I need to take Propanolol (Inderal)?´ Based on the nurse¶s understanding of the medication and Grave¶s disease. pallor diaphoresis and tachycardia. ³The medication limit synthesis of the thyroid hormones. the nurse should include in her care: A.´ C. ³The medication will increase the synthesis of thyroid hormones.happens to be a diabetic. who is newly diagnosed with Graves disease. An adult. bleeding is a potential complication. The next best action for the nurse to take is to: A.´ Answer: (C) ³The medication will block the cardiovascular symptoms of Grave¶s disease. ³The medication will block the cardiovascular symptoms of Grave¶s disease. Call the guest¶s personal physician C. 31. the nurse should watch out for signs of hypoglycemia manifested by dizziness. Checking the back and sides of the operative dressing B. if unconscious. Supporting the head during mild range of motion exercise C. hard candy. Offer the guest a cup of coffee D. tremors. weakness. Give the guest a glass of orange juice Answer: (D) Give the guest a glass of orange juice In diabetic patients. Encourage the guest to eat some baked macaroni B.
and clear of drainage. 35. Progressive weight gain D. Keep legs elevated on 2 pillows while sleeping D. Inspect feet and legs daily for any changes C. 34. On discharge. causing erratic insulin absorption rates from these D. Dry skin and fatigue C. Poor rotation technique can cause superficial hemorrhaging C. Which of the following would be inappropriate to include in a diabetic teaching plan? A. a decrease in thyroid hormone production. Injection sites can never be reused Answer: (C) Lipodystrophic areas can result. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops: A. Insomnia and excitability Answer: (C) Progressive weight gain Hypothyroidism. Change position hourly to increase circulation B. causing erratic insulin absorption rates from these Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Lipodystrophy can result and is extremely painful B. the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. Keeping the legs elevated during sleep will further cause circulatory impairment. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions. Lipodystrophic areas can result. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin? A. 33. Keep the insulin not in use in the refrigerator Answer: (C) Keep legs elevated on 2 pillows while sleeping The client with DM has decreased peripheral circulation caused by microangiopathy. Intolerance to heat B. . is characterized by hypometabolism that manifests itself with weight gain.
RUQ pain that increases after meal C. hungerlike pain in the epigastric area that is relieved by food intake Duodenal ulcer is related to an increase in the secretion of HCl. The most . Maintain NGT to intermittent suction B. after gastroscopy. Sharp pain in the epigastric area that radiates to the right shoulder D. aching. This can be buffered by food intake thus the relief of the pain that is brought about by food intake. Post-operatively. Giving fluids and food at this time can lead to aspiration. Assess gag reflex prior to administration of fluids C. after gastroscopy. Giving fluids and food at this time can lead to aspiration. dull. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client. hungerlike pain in the epigastric area that is relieved by food intake B. Assess for pain and medicate as ordered D. Assess gag reflex prior to administration of fluids C. Which description of pain would be most characteristic of a duodenal ulcer? A. the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. A sensation of painful pressure in the midsternal area Answer: (A) Gnawing. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client. 37. The client underwent Billroth surgery for gastric ulcer. dull. aching. Included in the plan of care for the immediate post-gastroscopy period will be: A. Maintain NGT to intermittent suction B.36. Assess for pain and medicate as ordered D. 36. Included in the plan of care for the immediate post-gastroscopy period will be: A. Gnawing. has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. 38. has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure.
Which of the following should the nurse exclude in the plan of care? A. Notify the MD of your findings C. the client developed dumping syndrome. Treatment will include Ranitidine and Antibiotics B. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium¶s resistance to acid digestion. Take only sips of H2O between bites of solid food C. 39. Reduce the amount of simple carbohydrate in the diet Answer: (A) Sit upright for at least 30 minutes after meals The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying. Giving antibiotics will control the infection and Ranitidine. Reposition the NGT by advancing it gently NSS B. To delay the emptying. the client has to lie down after meals. Which of the following statements indicate an understanding of this data? A. Irrigate the NGT with 50 cc of sterile D. After Billroth II Surgery. causing distention of the duodenum or jejunum produced by a bolus of food. Eat small meals every 2-3 hours D. Sit upright for at least 30 minutes after meals B. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Discontinue the low-intermittent suction Answer: (B) Notify the MD of your findings The client¶s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. 40. Pylori infection. which is a histamine-2 blocker. No treatment is necessary at this time C.appropriate nursing action is to: A. will reduce acid . Sitting up after meals will promote the dumping syndrome. Surgical treatment is necessary Answer: (A) Treatment will include Ranitidine and Antibiotics One of the causes of peptic ulcer is H. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention. This result indicates gastric cancer caused by the organism D.
Codeine Answer: (C) Meperidine Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations. ³Because of portal hyperemesis.´ Answer: (A) ³The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system. 43. A protein-restricted diet will therefore decrease ammonia production. ³Most people have too much protein in their diets. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. 42. 41. Meperidine D. Empty bladder before procedure C. The amount of this diet is better for liver healing.secretion that can lead to ulcer.´ The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract.´ B. What statement by the nurse would best explain the purpose of the diet? A.´ C. What instructions should the client be given before undergoing a paracentesis? A. ³The liver heals better with a high carbohydrates diet rather than protein. Strict bed rest following procedure D. Demerol is . NSAIDS C. Morphine B. NPO 12 hours before procedure B. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure. ³The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.´ D. Which of the drug of choice for pain controls the patient with acute pancreatitis? A. Empty bowel before procedure Answer: (B) Empty bladder before procedure Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus.
encouraging the client to take adequate deep breaths by mouth B. Because of these symptoms the nurse should be alert for other problems associated with what disease? A. clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. changing the dressing at least BID D. Peritonitis Answer: (B) Ulcerative colitis . Deflate the esophageal balloon B. it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction 46. The first action of the nurse is to: A. Immediately after cholecystectomy. irrigate the T-tube frequently Answer: (B) encouraging the client to cough and deep breathe Cholecystectomy requires a subcostal incision. Monitor VS C. Upon insertion of the tube. the client complains of difficulty of breathing. Deep breathing and coughing exercises can help prevent such complications. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Encourage him to take deep breaths D. severe abdominal pain. Notify the MD Answer: (A) Deflate the esophageal balloon When a client with a Sengstaken-Blakemore tube develops difficulty of breathing. Diverticulitis D. Chrons disease B. 44. Ulcerative colitis C. To minimize pain. 45. The client presents with severe rectal bleeding. encouraging the client to cough and deep breathe C.the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic. tenesmus and dehydration. the nursing action that should assume the highest priority is: A. 16 diarrheal stools a day.
slows transport of materials through the gut which has been linked to colorectal cancer. Cover the wound with sterile. Days after abdominal surgery. moist saline dressing .´ Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet.´ D. The client has a good understanding of the means to reduce the chances of colon cancer when he states: A.´ Answer: (D) ³I will include more fresh fruits and vegetables in my diet.Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. ³I will include more red meat in my diet. Give laxative the night before and a cleansing enema in the morning before the test B. To obtain accurate results in this procedure. ³I will include more fresh fruits and vegetables in my diet. the nurse should: A. the bowels must be emptied of fecal material thus the need for laxative and enema. A client is being evaluated for cancer of the colon. ³I will exercise daily. pus and mucus. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood.´ B. such as when fresh fruits and vegetables are minimal or lacking in the diet. The other symptoms mentioned accompany the problem. In preparing the client for barium enema. ³I will have an annual chest x-ray. 49. The safest nursing intervention when this occurs is to A. the client¶s wound dehisces.´ C. Instruct the client to swallow 6 radiopaque tablets the evening before the study D. Place the client on CBR a day before the study Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. Render an oil retention enema and give laxative the night before C. 48. 47.
Answer: (B) Ambulate. Her electrolytes are sodium 120 mEq/L. The client is displaying signs of which electrolyte imbalance? A. pulse 110.4°F (38°C). Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination. When this occurs. potassium 5. age 35. 50. C. B. He is believed to have a small stone that will pass spontaneously. respirations 30. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process. Ambulate. Hold the abdominal contents in place with a sterile gloved hand Answer: (A) Cover the wound with sterile. and oral temperature 100. nausea and vomiting and abdominal cramps. Hyponatremia B. moist saline dressing Dehiscence is the partial or complete separation of the surgical wound edges. has a renal calculus. Hyperkalemia C. D. oriented. and complaining of severe back pain. 51. alert. Approximate the wound edges with tapes C. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting . her urinary output for the first 8 hours is 50 ml. Strain all urine. Hyperphosphatemia D. the nurse would instruct the client to force fluids and to A. The client¶s serum sodium is below normal. A female client is admitted with a diagnosis of acute renal failure. Irrigate the wound with sterile saline D. To increase the chance of the stone passing. Hypercalcemia Answer: (A) Hyponatremia The normal serum sodium level is 135 ± 145 mEq/L. An intravenous pyelogram reveals that Paulo. Ask for medications to relax him. She is awake. Remain on bed rest.2 mEq/L. the client is placed in low Fowler¶s position and instructed to lie quietly.B. Her vital signs are blood pressure 100/70 mm Hg.
In the client with an external shunt. creatinine l. Decreased serum calcium. draw blood. TURP is the most common operation for BPH. 54.0 mg/dl D. don¶t use the arm with the vascular access site to take blood pressure readings. Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. blood pH 7.2. increased serum calcium. Avoid taking blood pressure measurements or blood samples from the affected arm. Which nursing action would be of highest priority with regard to the external shunt? A. creatinine 0. Instruct the client not to use the affected arm. potassium 6. It would be inappropriate to include which of the following points in the preoperative teaching? A. Romeo Diaz. BUN 35 to 40 mg/dl. The serum Ca decreases as the kidneys fail to excrete phosphate.5 to 1. pH 7. BUN 10 to 30 mg/dl.35. 53. age 78. blood pH 7. D.2. He is scheduled for a transurethral resection of the prostate (TURP). potassium 3. B. potassium 4.0 mEq/L. Assessing the laboratory findings. Heparinize it daily.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. Change the Silastic tube daily. insert IV lines. potassium 6. or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt. BUN 15 mg/dl.52. decreased serum calcium Answer: (B) Decreased serum calcium. . potassium and hydrogen ions are retained. which result would the nurse most likely expect to find in a client with chronic renal failure? A.5 mg/dl B.5 mEq/L. With the loss of renal function. the kidneys ability to regulate fluid and electrolyte and acid base balance results. Treatment with hemodialysis is ordered for a client and an external shunt is created. C. is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH).5 mEq/L C.
Answer: (D) He will be pain free. Telling the pain that he will be pain free is giving him false reassurance. the appendix is anatomically located at the Mc Burney¶s point at the right iliac area of the right lower quadrant. Discharge teaching should include A. the nurse should be looking for tenderness on palpation at McBurney¶s point. 22% . Surgical interventions involve an experience of pain for the client which can come in varying degrees. She sustained severe burns of the face. On physical examination. right lower quadrant D.B.neck. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. which will clear as healing takes place. C. recommending him to drink eight glasses of water daily Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. 56. Using the rule of nines. Mr. telling him to avoid heavy lifting for 4 to 6 weeks B. left lower quadrant B. telling him to resume his previous daily activities without limitations D. which is located in the A. 55. which is the best estimate of total body-surface area burned? A. D. Expect bloody urine. right upper quadrant Answer: (C) right lower quadrant To be exact. anterior chest. The fluid intake of eight glasses a day is good advice but is not a priority in this case. left upper quadrant C. 18% B. A 30-year-old homemaker fell asleep while smoking a cigarette. There is no special diet required. instructing him to have a soft bland diet for two weeks C. Explain the purpose and function of a two-way irrigation system. Valdez has undergone surgical repair of his inguinal hernia. and both arms and hands. 57. He will be pain free.
perineum. An increase in the total volume of intracranial plasma B. and dyspnea Burns located in the upper torso. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.C. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: A. 60. especially resulting from thermal injury related to fires can lead to inhalation burns. Establishing a patent IV line for fluid replacement Answer: (C) Frequently observing for hoarseness.each upper extremity.front chest and abdomen. 18% . 9% . Excessive renal perfusion with diuresis C. 18%. Fluid shift from intravascular space to the interstitial space Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase.each lower extremity and 1% . Frequently observing for hoarseness. and dyspnea D. noisy and difficult breathing.entire back. 31% D. which nursing measure would be least effective to help prevent contractures? . If a burn is located on the upper torso. Debriding and covering the wounds B.head. which item would be a primary concern? A. If a client has severe bums on the upper torso. 18% . 40% Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned. 59. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness. stridor. Maintaining a patent airway is a primary concern. 58. stridor. we allot the following: 9% . Contractures are among the most serious long-term complications of severe burns. Fluid shift from interstitial space D. Administering antibiotics C.
Aluminum hydroxide Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. Looking at the following labeled solutions. A nurse is directed to administer a hypotonic intravenous solution. All the other medications mentioned help treat hyperkalemia and its effects. electrolytes. But this approach can lead to contracture deformities and other complications. Calcium glucomite D. 63. An adult is receiving Total Parenteral Nutrition (TPN). Avoiding the use of a pillow for sleep. Which drug would be least effective in lowering a client's serum potassium level? A. assess the bowel sound D. Changing the location of the bed or the TV set. it is important to monitor the clients fluid intake and output including electrolytes. or both. vitamins. evaluation of the peripheral IV site B.A. confirmation that the tube is in the stomach C. 62. The admixture is made up of proteins. fluid and electrolyte monitoring Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. Which of the following assessment is essential? A. Polystyrene sulfonate (Kayexalate) C. daily B. fats. Glucose and insulin B. blood glucose and weight. Because of its composition. carbohydrates. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. It is intended to improve the clients nutritional status. 61. Encouraging the client to chew gum and blow up balloons C. trace minerals and sterile water based on individual client needs. she should choose . Helping the client to rest in the position of maximal comfort Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. or placing the head in a position of hyperextension D.
A. decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT A.45% NaCl has a lower tonicity that the blood. 40 years old. assessing Maria's expectations and doubts C. Maria refuses to acknowledge that her breast was removed. Maria Sison. 65. assuring Maria that she will be cured of cancer B. one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. 66. The SNS stimulation constricts renal arterioles that increases release of aldosterone. D5W D. tachycardia D. oliguria C. 0. keeping Maria's visitors to a minimum so she can have time for herself Answer: (B) assessing Maria's expectations and doubts Assessing the client¶s expectations and doubts will help lessen her fears and anxieties. maintaining a cheerful and optimistic environment D. 0. was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. single. D5NSS Answer: (A) 0. A patient is hemorrhaging from multiple trauma sites. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed. She believes . Nursing care during the preoperative period should consist of A. and D5NSS is hypertonic with a higher tonicity thab the blood.45% NaCl B. 0.45% NaCl Hypotonic solutions like 0. hypertension B. 64.9% NaCl and D5W are isotonic solutions with same tonicity as the blood.9% NaCl C. tachypnea Answer: (A) hypertension In hypovolemia.
followed by bargaining. C. depression and last acceptance. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. Answer: (B) recognize that Kathy is experiencing denial. The initial stage in the grieving process is denial. recognize that Kathy is experiencing denial. Endoscopy provides direct view of a body cavity to detect abnormality. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. thus the effect of bone marrow depression. reinforce Kathy¶s belief for several days until her body can adjust to stress of surgery. CT scanning uses magnetic fields and radio frequencies to provide crosssectional view of tumor D. then anger. 67. D. it affects both normal and tumor cells C. The nurse should A. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises.that her breast is intact under the dressing. statements about chemotherapy is true? A. 68. a normal stage of the grieving process A person grieves to a loss of a significant object. it has been proven as a complete cure for cancer D. Which of the ff. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. it is a local treatment affecting only tumor cells B. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? A. a normal stage of the grieving process C. it is often used as a palliative measure. call the MD to change the dressing so Kathy can see the incision B. The nurse should show acceptance of the patient¶s feelings and encourage verbalization. Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor . Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells.
The inability of the kidneys to excrete the drug metabolites B. ³I will try not to cough. This is caused by: A. A post-operative complication of mastectomy is lymphedema. 71. Answer: (D) frequently elevating the arm of the affected side above the level of the heart. Toxic effect of the antibiotic that are given concurrently D.´ Children have cells that are normally actively dividing in the process of growth. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix? A. The altered blood ph from the acid medium of the drugs . MRI uses magnetic fields and radio frequencies to detect tumors.´ B. placing the arm on the affected side in a dependent position C. 69. High uric acid levels may develop in clients who are receiving chemotherapy.´ C. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself. ensuring patency of wound drainage tube B. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling. 70. ³I should get out of bed and walk around in my room. This can be prevented by A. ³My 7 year old twins should not come to visit me while I¶m receiving treatment.CT scan uses narrow beam x-ray to provide cross-sectional view. frequently elevating the arm of the affected side above the level of the heart. Rapid cell catabolism C. but they are not necessary for anyone else who comes in here.´ D. because the force might make me expel the application. ³I know that my primary nurse has to wear one of those badges like the people in the x-ray department.´ Answer: (B) ³My 7 year old twins should not come to visit me while I¶m receiving treatment. restricting movement of the affected arm D.
below the level of the heart Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. into the bloodstream faster than the body can eliminate them. Active range of motion exercises of the arms once a day. C. washing or combing with the affected arm D. is caused by the rapid destruction of large number of tumor cells. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm 74. Low residue diet D. the tumor lysis syndrome. They can precipitate in the kidneys and block the tubules causing acute renal failure. Unlimited visitors C. Nursing actions throughout this phase . Frequent ambulation B. including potassium and purines. 72. Mobility and vaginal irrigations are not done. Avoid BP measurement and constricting clothing on the affected arm B. Which of the following interventions would be included in the care of plan in a client with cervical implant? A. The nurse assesses that the client has entered the second phase of acute renal failure. Intracellular contents are released. Discourage feeding. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions 73. . Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? A.Answer: (B) Rapid cell catabolism One of the oncologic emergencies. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. Vaginal irrigation every shift Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. Place the affected arm in a dependent position.
Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. D. 76. Checking on the VS especially the RR. 75. hypokalemia. wide fluctuations in serum sodium and potassium levels. B. Decreased physiologic functioning C. assessing her VS especially her RR Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. and hypernatremia. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival. When she arrives in the RR she is still in shock. placing her in a trendeleburg position B. Hypervolemia. Hypovolemia. and hypernatremia. Hypervolemia. is a priority to help detect its progress and provide for prompt management before the occurrence of complications. Hypovolemia. Answer: (C) Hypovolemia. no fluctuation in serum sodium and potassium levels. A rapid pulse and increased RR B. putting several warm blankets on her C. When assessing the client. The second phase of ARF is the diuretic phase or high output phase. Increased awareness and attention Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. . which detects need for oxygenation. An adult has just been brought in by ambulance after a motor vehicle accident. monitoring her hourly urine output D. Ms. wide fluctuations in serum sodium and potassium levels. The diuresis can result in an output of up to 10L/day of dilute urine. C. The nurse's priority should be A.include observation for signs and symptoms of A. hyperkalemia. the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? A. Rigid posture and altered perceptual focus D. Loss of fluids and electrolytes occur.
and no fluid or air is found. but the client's vital signs do not improve. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Intervention for a pt. A thoracentesis is performed on a chest-injured client.77. . The most likely cause of these findings is which of the following? A. Blood and fluids is administered intravenously (IV). administering an irritant that will stimulate vomiting B. and the initial reading is 20 cm H^O. Elevated hematocrit levels. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. Normal renal perfusion should produce 1ml/kg of BW/min. 79. aspirating secretions from the pharynx if respirations are affected C. C. Hypovolemia is a decreased in circulatory volume. Answer: (B) Urine output of 30 to 50 ml/hr. who has swallowed a Muriatic Acid includes all of the following except A. A central venous pressure line is inserted. 78. Hemothorax D. This causes a decrease in tissue perfusion to the different organs of the body. Estimate of fluid loss through the burn eschar. Urine output of 30 to 50 ml/hr. This leads to right atrial and venous congestion manifested by a CVP reading above normal. Pericardial tamponade Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. B. D. The best indicator of adequate fluid balance during this period is A. Ruptured diaphragm C. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance. Change in level of consciousness. washing the esophagus with large volumes of water via gastric lavage . neutralizing the chemical D. Spontaneous pneumothorax B.
Flushing of the lids. Chemical burn of the eye are treated with A. hot compresses applied at 15-minute intervals C. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Measures are taken to immediately remove the toxin or reduce its absorption. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Positive Babinski's reflex Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which. gastric emptying procedure is immediately instituted.Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Pupils equal and react to light C. 80. is the primary goal of CPR. Palpable carotid pulse D. In the hospital. . local anesthetics and antibacterial drops for 24 ± 36 hrs. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. instillation of local anesthetic and antibiotic is done. The Heimlich maneuver (abdominal thrust). Signs of effective tissue perfusion will be noted after. Vomiting is only indicated when non-corrosive poison is swallowed. together with the return of breathing. copious irrigation with normal saline. conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. such as in muriatic acid where burn or perforation of the mucosa may occur. Skin warm and dry B. B. This includes gastric lavage and the administration of activated charcoal to absorb the poison. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? A. 82. for acute airway obstruction. conjunctiva and cornea with tap or preferably sterile water D. For corrosive poison ingestion. cleansing the conjunctiva with a small cotton-tipped applicator Answer: (C) Flushing of the lids. 81.
They go into a stage of denial and anger in their grieving. 84. 16 years old. When his parents arrive at the hospital. forces air out of the lungs and creates an artificial cough that expels the aspirated material. speak to both parents together and encourage them to support each other and express their emotions freely C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. John. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the .attempts to: A. Assisting them with information they need to know. Increase systemic circulation C. increase BP B. relax the bronchial smooth muscle D. ask them to stay in the waiting area until she can spend time alone with them B. Put pressure on the apex of the heart Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. 83. He is pronounced dead on arrival. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. decrease bronchial secretions Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. This is given to: A. ask the MD to medicate the parents so they can stay calm to deal with their son¶s death. the nurse should: A. Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. Force air out of the lungs B. is brought to the ER after a vehicular accident. The pressure from the thrusts lifts the diaphragm. Induce emptying of the stomach D. decrease mucosal swelling C. answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.
straining to have a bowel movement C. 85. coughing and blowing the nose B. upper third of the sternum C. ³As one ages.´ Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. ³You should rest your eyes frequently. lower half of the sternum D.bronchial smooth muscles. . 87. lower third of the sternum Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. This is normal. upper half of the sternum B. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision. sneezing. visual changes are noted as part of degenerative changes. Which of the following activities is not encouraged in a patient after an eye surgery? A. When performing chest compressions.´ Answer: (B) ³As one ages. sexual intercourse Answer: (D) sexual intercourse To reduce increases in IOP. 86. ³You maybe able to improve you vision if you move slowly.´ D. The nurse is performing an eye examination on an elderly client. and I don¶t easily see clearly when I get into a dark room.´ The nurse best response is: A.´ B. teach the client and family about activity restrictions. the nurse understands the correct hand placement is located over the A.´ C. wearing tight shirt collars D. This is normal. ³You should be grateful you are not blind. The client states µMy vision is blurred. visual changes are noted as part of degenerative changes. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration. A nurse is performing CPR on an adult patient.
A client is to undergo lumbar puncture. Speak clearly in a loud voice or shout to be heard D. 88. Assess movements and sensation in the lower extremities after the D. LP involves the removal of some amount of spinal fluid. The affected extremity must be kept straight and immobilized during the duration of the . The platelets are attracted to the area causing thrombi formation. for 24 to 48 hrs after the procedure. Converse in a quiet room with minimal distractions Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. Answer: (D) Force fluids before and after the procedure. the client is instructed to increase fluid intake to 3L. B. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. C. Kept the extremity used as puncture site flexed to prevent bleeding. Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. 90. unless contraindicated. Check pulse. Force fluids before and after the procedure. Use appropriate hand motions B. color and temperature of the extremity distal to the site of D. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. To facilitate CSF production. Which is least important information about LP? A. Keep hands and other objects away from your mouth when talking to the client C.Sexual intercourse can cause a sudden rise in IOP. Maintain pressure dressing over the site of puncture and check for C. Specimens obtained should be labeled in their proper sequence. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. It may be used to inject air. Nursing care of the client includes the following EXCEPT A. It is enough for the nurse to speak clearly and slowly. Inform the client that a warm. 89. dye or drugs into the spinal canal. flushed feeling and a salty taste may be B. Which of the following indicates poor practice in communicating with a hearing-impaired client? A.
bedrest after the procedure. rising systolic and widening pulse pressure C. Anticonvulsants are given to prevent seizures C. Which is irrelevant in the pharmacologic management of a client with CVA? A. The primary goal in the management of CVA is to improve cerebral tissue perfusion. contralateral hemiparesis and ipsilateral dilation of the pupils D. This is initially manifested by restlessness. Encourage the client to speak at every possible opportunity. Communicate by means of questions that can be answered by the client shaking the head C. Keep us a steady flow rank to minimize silence D. progression from restlessness to confusion and disorientation to lethargy Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. What would be the MOST therapeutic nursing action when a client¶s expressive aphasia is severe? A. abnormal respiratory pattern B. 91. 92. Thrombolytics are most useful within three hours of an occlusive CVA D. Expressive or motor aphasia is a result of damage in the Broca¶s area of the . Answer: (D) Aspirin is used in the acute management of a completed stroke. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticipate the client wishes so she will not need to talk B. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding. Ice bag can be applied intermittently to the puncture site. Aspirin is used in the acute management of a completed stroke. Answer: (D) Encourage the client to speak at every possible opportunity. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for? A. 93.
Which of the following nursing diagnosis is most important at this time? A. altered level of cognitive function B. This leads to sporadic. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. High risk for injury related to muscle weakness C. drowsy and has unequal pupils. Ineffective airway clearance related to muscle weakness Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. 96. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively. 94. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? A. A client with head injury is confused. How can the nurse determine if the drainage is CSF? A. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. high risk for injury C. sensory perceptual alteration Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Measure the ph of the fluid B. Test for glucose . Measure the specific gravity of the fluid C. Pain B. 95. altered cerebral tissue perfusion D. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.frontal lobe. The client has clear drainage from the nose and ears after a head injury. Ineffective coping related to illness D.
pillow on a foot-stool).D. Slide items across the floor rather than lift them. The nurse should see to it therefore that objects are within easy reach of the patient. Place items so that it is necessary to bend or stretch to reach them. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb.. A 70-year-old female comes to the clinic for a routine checkup. A client is admitted from the emergency department with severe-pain and . and inspect the stump daily. She is retired and has had to give up her volunteer work because of her discomfort. Toughen the stump by pushing it against a progressively harder substance (e. C. She was told her diagnosis was osteoarthritis about 5 years ago. Decrease the calorie count of her daily diet. A positive result with the drainage indicate CSF leakage. Overreaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. 99. Wash. D. Treat superficial abrasions and blisters promptly. 97. Test for chlorides Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. It should be applied with the distal end with the tighter arms. Patients with osteoarthritis have decreased mobility caused by joint pain. C. B. The ³shrinker´ bandage is applied to prevent swelling of the stump.g. Answer: (D) Place items so that it is necessary to bend or stretch to reach them. Which measure would be excluded from the teaching plan? A. Take warm baths when arising. Which would be excluded from the clinical pathway for this client? A. She is 5 feet 4 inches tall and weighs 180 pounds. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. D. 98. Her major complaint is pain in her joints. B. dry.
Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. Before log rolling. encouraging discussion about lifestyle changes D. Ensure an intake of at least 3000 ml of fluid per day. His diagnosis is gouty arthritis. C. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. Apply hot compresses to the affected joints. as a priority in the plan of care? A. C. remove the pillow from under the client's head and use no pillows between the client's legs. it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing. 100. place a pillow under the client's head and a pillow between the client's legs. Administer salicylates to minimize the inflammatory reaction. B. When developing a plan of care. A client had a laminectomy and spinal fusion yesterday. protecting the client from infection C. The nurse would incorporate which of the ff. Which statement is to be excluded from your plan of care? A. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones. providing emotional support to decrease fear B. B. Following a laminectomy and spinal fusion. remove the pillow from under the client's head and use no pillows between the client's legs. Keep the knees slightly flexed while the client is lying in a semi-Fowler's position in bed. which action would have the highest priority? A. D. Answer: (B) Before log rolling. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day. Stress the importance of maintaining good posture to prevent deformities. So it is the nurse¶s primary responsibility to protect the .edema in the right foot. Keep a pillow under the client's head as needed for comfort. Before log rolling. 101. identifying factors that decreased the immune function Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. D.
The drop factor of the IV set is 10 gtt/ml. is admitted to the hospital after an automobile accident.patient from infection. an obese 32 year old. the value of aerobic exercises in her weight reduction program. the nurse should bear in mind that long-term weight loss best occurs when: A. 45 gtt/min Answer: (A) 25 gtt/min To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20) 103. After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. Eating habits are altered C. Decrease her appetite D. Lower her metabolic rate C. Raise her heart rate . The nurse would know that this teaching was effective when Joy says that exercise will: A. She has a fractured hip and is brought to the OR for surgery. Joy. a new dietary program. 25 gtt/min B. Fats are controlled in the diet B. The nurse teaches Joy. an obese client. 30 gtt/min C. 102. 35 gtt/min D. must be established and continued 104. Before answering her question. Carbohydrates are regulated D. with a balance of foods from the basic four food groups. The nurse should set the piggyback to flow at: A. Increase her lean body mass B. The piggyback is to infuse in 20 minutes. The day after her surgery Joy asks the nurse how she might lose weight. Exercise is part of the program Answer: (B) Eating habits are altered For weight reduction to occur and be maintained.
Both feet placed wide apart C. He is diagnosed with a myocardial infarct. The vial on hand is labeled 1 ml/ 10 mg. He is 5 feet. The physician orders 8 mg of Morphine Sulfate to be given IV. The most important activity to facilitate walking with crutches before ambulation begun is: A. 15 minims . The nurse should administer: A. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on: A. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. 10 minims C. Sitting up at the edge of the bed to help strengthen back muscles C. 106. Exercising the triceps. finger flexors. Using the trapeze frequently for pull-ups to strengthen the biceps muscles Answer: (A) Exercising the triceps. 105. 12 minims D. Doing isometric exercises on the unaffected leg D. Her axillary regions Answer: (C) The palms of her hands The palms should bear the client¶s weight to avoid damage to the nerves in the axilla (brachial plexus) 107. finger flexors. 8 minims B. The physician orders non-weight bearing with crutches for Joy. Morphine sulfate. Diazepam (Valium) and Lidocaine are prescribed.Answer: (A) Increase her lean body mass Increased exercise builds skeletal muscle mass and reduces excess fatty tissue. and elbow extensors B. who had surgery for a fractured hip. The palms and axillary regions B. The palms of her hands D. and elbow extensors These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation. 8 inches tall and weighs 190 pounds.
thus precautionary measures are important regarding its use. AST . Will help prevent erratic heart beats B. 110. CK-MB D. Has unstable properties C. Myra is ordered laboratory tests after she is admitted to the hospital for angina. Relieves pain and decreases level of anxiety C. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand. 109. Converts to an alternate form of matter B. SGPT B. The nurse replies that it: A. LDH C. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. Decreases anxiety D. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. Dilates coronary blood vessels Answer: (B) Relieves pain and decreases level of anxiety Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. Supports combustion D. Is flammable Answer: (C) Supports combustion The nurse should know that Oxygen is necessary to produce fire.Answer: (C) 12 minims Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate 108. The isoenzyme test that is the most reliable early indicator of myocardial insult is: A. The nurse institutes safety precautions in the room because oxygen: A.
An early finding in the EKG of a client with an infarcted mycardium would be: A. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand. including: . 113. has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to: A.Answer: (C) CK-MB The cardiac marker. Flattened T waves Answer: (B) Elevated ST segments This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. frustrations and anger about his condition C. Explain how his being upset dangerously disturbs his need for rest D. frustrations and anger about his condition This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. They are therefore most reliable in assisting with early diagnosis. Allow him to release his feelings and then leave him alone to allow him to regain his composure B. Creatinine phosphokinase (CPK) isoenzyme levels. 111. 112. Twenty four hours after admission for an Acute MI. The other choices are not typical of MI. Elevated ST segments C. Absence of P wave D. begin to rise in 3-6 hours. Refocus the conversation on his fears.3 C. Jose. The nurse monitors him for other adaptations related to the pyrexia. Attempt to explain the purpose of different hospital routines Answer: (B) Refocus the conversation on his fears. Jose¶s temperature is noted at 39. who had a myocardial infarction 2 days earlier. peak in 1218 hours and are elevated 48 hours after the occurrence of the infarct. especially the MB sub-unit which is cardio-specific. Disappearance of Q waves B. The cardiac markers elevate as a result of myocardial tissue damage.
Store vitamin B12 B. is admitted to the hospital to rule out pernicious anemia. Answer: (C) Avoid giving him direct information and help him explore his feelings To help the patient verbalize and explore his feelings. Ana. Shortness of breath B. chest pain and shortness of breath are not typically noted in fever. Chest pain C. A Schilling test is ordered for Ana. Tell him that he certainly needs to be especially careful about his diet and lifestyle. 114.A. who is admitted to the hospital for chest pain. The nurse recognizes that the primary purpose of the Schilling test is to determine the client¶s ability to: A. Increased BP. Digest vitamin B12 C. Suggest he discuss his feelings of vulnerability with his physician. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor. C. This need for oxygen increases the heart rate. which is reflected in the increased pulse rate. Avoid giving him direct information and help him explore his feelings D. Absorb vitamin B12 D. Increased pulse rate Answer: (D) Increased pulse rate Fever causes an increase in the body¶s metabolism. In the Schilling test. Elevated blood pressure D. asks the nurse. radioactive vitamin B12 is administered and its absorption and excretion can be . the nurse must reflect and analyze the feelings that are implied in the client¶s question. 55 years old. 115. The focus should be on collecting data to minister to the client¶s psychosocial needs. which results in an increase in oxygen consumption and demand. Jose. Produce vitamin B12 Answer: (C) Absorb vitamin B12 Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. B. ³Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?´ The most appropriate initial response would be for the nurse to: A.
ascertained through the urine.
116. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer: A. 0.5 ml B. 1.0 ml C. 1.5 ml D. 2.0 ml Answer: (D) 2.0 ml First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
117. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include: A. Oral tablets of Vitamin B12 will control her symptoms B. IM injections are required for daily control C. IM injections once a month will maintain control D. Weekly Z-track injections provide needed control Answer: (C) IM injections once a month will maintain control Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
118. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it: A. When she feels fatigued B. During exacerbations of anemia C. Until her symptoms subside D. For the rest of her life Answer: (D) For the rest of her life Since the intrinsic factor does not return to gastric secretions even with therapy,
B12 injections will be required for the remainder of the client¶s life.
119. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his ³wound looks terrible.´ The nurse recognizes that the client is using the defense mechanism known as: A. Reaction Formation B. Sublimation C. Intellectualization D. Projection Answer: (D) Projection Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
120. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure: A. When the client would have normally had a bowel movement B. After the client accepts he had a bowel movement C. Before breakfast and morning care D. At least 2 hours before visitors arrive Answer: (A) When the client would have normally had a bowel movement Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
121. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he: A. Stops the flow of fluid when he feels uncomfortable B. Lubricates the tip of the catheter before inserting it into the stoma C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
122. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician : A. Abdominal cramps during fluid inflow B. Difficulty in inserting the irrigating tube C. Passage of flatus during expulsion of feces D. Inability to complete the procedure in half an hour Answer: (B) Difficulty in inserting the irrigating tube Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
123. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing: A. A reaction formation to his recent altered body image. B. A difficult time accepting reality and is in a state of denial. C. Impotency due to the surgery and needs sexual counseling D. Suicide thoughts and should be seen by psychiatrist Answer: (B) A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client¶s denial is supported
124. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat: A. Food low in fiber so that there is less stool B. Everything he ate before the operation but will avoid those foods that cause gas C. Bland foods so that his intestines do not become irritated D. Soft foods that are more easily digested and absorbed by the large intestines Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should
125. The most appropriate nursing action would be to A. Assess his response to the equipment D.be avoided. the assessment that assume the greatest priority are: A. It is feared his leg may have to be amputated. the client¶s chest tube seems to be obstructed. He has suffered multiple crushing wounds of the chest. Eddie. a plane crash victim. is brought to the emergency room after the crash of his private plane. A few hours later. Prepare for chest tube removal B. Milk the tube toward the collection container as ordered . The most immediate nursing intervention for him at this time would be to: A. Respiratory rate and blood pressure D. Abdominal contusions and other wounds C. Pain. Level of consciousness and pupil size B. abdomen and legs. These are top priorities to trauma management. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. Nothing is achieved if the equipment is working and the client is not responding 127. Facilitate his verbal communication B. Eddie. Maintain sterility of the ventilation system C. 40 years old. When Eddie arrives in the emergency room. Prepare him for emergency surgery Answer: (C) Assess his response to the equipment It is a primary nursing responsibility to evaluate effect of interventions done to the client. undergoes endotracheal intubation and positive pressure ventilation. Basic life functions must be maintained or reestablished 126. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Respiratory and cardiovascular functions are essential for oxygenation.
Complete safety of the procedure B. Pulse rates of 120 and 110 in a 15 minute period D. D. the observation that indicates adequate tissue perfusion to vital organs is: A. Risk of the procedure with his other injuries . heart and brain. Arrange for a stat Chest x-ray film. the nurse should emphasize in his teaching plan the: A. In preparing the client for surgery. Increased breath sounds B. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is: A. He begins to complain of increased abdominal pain in the left upper quadrant. 130. Constant bubbling in the drainage chamber C. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. which may be obstructing drainage. Expectation of postoperative bleeding C. Blood pressure readings of 50/30 and 70/40 within 30 minutes Answer: (A) Urinary output is 30 ml in an hour A rate of 30 ml/hr is considered adequate for perfusion of kidney. A client with multiple injury following a vehicular accident is transferred to the critical care unit. drains fluid and air from the pleural space. Clam the tube immediately Answer: (B) Milk the tube toward the collection container as ordered This assists in moving blood. Crepitus detected on palpation of chest D. toward the collection chamber 128. fluid or air. Urinary output is 30 ml in an hour B. Increased respiratory rate Answer: (A) Increased breath sounds The chest tube normalizes intrathoracic pressure and restores negative intrapleural pressure. Central venous pressure reading of 2 cm H2O C. and improves pulmonary function 129. In the evaluation of a client¶s response to fluid replacement therapy.C.
Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. he will be able to return to his normal lifestyle C. Turn him from side to side at least every 2 hours D. Continue observing for dyspnea and crepitus Answer: (B) Encourage frequent coughing and deep breathing This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange. the client is refusing to eat.D. 131. Extent of body change present . Emphasize repeatedly that with as prosthesis. talk or perform any rehabilitative activities. Give him explanations of why there is a need to quickly increase his activity B. Acceptance of the client¶s behavior is an important factor in the nurse¶s intervention. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture. 133. 132. Presence of abdominal drains for several days after surgery Answer: (D) Presence of abdominal drains for several days after surgery Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation. Three days postoperatively. The best initial nursing approach would be to: A. The key factor in accurately assessing how body image changes will be dealt with by the client is the: A. A client undergoes below the knee amputation following a vehicular accident. Encourage frequent coughing and deep breathing C. the nurse should: A. Appear cheerful and non-critical regardless of his response to attempts at intervention D. Encourage bed rest with active and passive range of motion exercises B.
Dennis receives a blood transfusion and develops flank pain. Obviousness of the change D. 134. fever and hematuria. The nurse should encourage the client to: A. Anemia and leucopenia are the two other problems noted with bone marrow depression. Intellectualization D. Increase his activity level and ambulate frequently B. but the client¶s feeling about the change that is the most important determinant of the ability to cope. Suddenness of the change C. Drink citrus juices frequently for nourishment D.B. Sublimation C. Sleep with the head of his bed slightly elevated C. Projection Answer: (C) Intellectualization People use defense mechanisms to cope with stressful events. Use a soft toothbrush and electric razor Answer: (D) Use a soft toothbrush and electric razor Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia. chills. The nurse recognizes that Dennis is probably experiencing: A. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. An anaphylactic transfusion reaction B. 135. 136. The laboratory results of the client with leukemia indicate bone marrow depression. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. The client should be encouraged to his feelings. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets. The nurse recognizes that Larry is using the defense mechanism known as: A. An allergic transfusion reaction . Reaction formation B. decreased platelets. Client¶s perception of the change Answer: (D) Client¶s perception of the change It is not reality.
Agree with and encourage the client¶s denial B. the best nursing approach is to: A.´ B. A client jokes about his leukemia even though he is becoming sicker and weaker. and it permits future movement through the grieving process when the client is ready. and capillary plugging that can damage renal function. During and 8 hour shift. these signs result from RBC hemolysis. ³Why are you always laughing?´ D. A hemolytic transfusion reaction D. During this 8 hour period.C. 139. 137. Reassure the client that everything will be okay C. also called type II hypersensitivity. +235 ml D. +55 ml B. his fluid balance would be: A. 138. cries on the inside. The nurse¶s most therapeutic response would be: A. Leave the client alone to discuss the loss Answer: (C) Allow the denial but be available to discuss death This does not take away the client¶s only way of coping. cups of tea and vomits 125 ml of fluid. In dealing with a dying client who is in the denial stage of grief. +485 ml . Allow the denial but be available to discuss death D.´ C. thus the flank pain and hematuria and the other manifestations. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages. +137 ml C. A pyrogenic transfusion reaction Answer: (C) A hemolytic transfusion reaction This results from a recipient¶s antibodies that are incompatible with transfused RBC¶s. ³Your laugher is a cover for your fear. Mario drinks two 6 oz. ³Does it help you to joke about your illness?´ Answer: (D) ³Does it help you to joke about your illness?´ This non-judgmentally on the part of the nurse points out the client¶s behavior. ³He who laughs on the outside. agglutination.
Collecting duct C.5 lbs weight loss equals approximately 2 Liters. The physician orders on a client with CHF a cardiac glycoside. The nurse understands Lasix exerts is effects in the: A.5 L Answer: (C) 2. a vasodilator. After 2 days of diuretic therapy he weighs 205. Mr.Answer: (C) +235 ml The client¶s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid. 142. Distal tubule B. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.5 L B.0 L C. Ascending limb of the loop of Henle Answer: (D) Ascending limb of the loop of Henle This is the site of action of Lasix being a potent loop diuretic. Dyspnea on exertion C. 141. and furosemide (Lasix). Crushing chest pain B.5 lbs. Extensive peripheral edema D.0 L D. Jugular vein distention Answer: (B) Dyspnea on exertion Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed. Mr.2 lbs. the nurse should expect to find: A. . In the assessment. 0. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. Glomerulus of the nephron D. The nurse could estimate that the amount of fluid he has lost is: A. Therefore a 4.0 L One liter of fluid weighs approximately 2. 3. 2. Ong weighs 210 lbs on admission to the hospital. resulting in difficult breathing. 1. loss is subtracted from intake 140.
Potassium D. The nurse concludes that his pulse rate is most likely the result of the: A. 2200 calories B.143. Cardiac glycoside Answer: (D) Cardiac glycoside A cardiac glycoside such as digitalis increases force of cardiac contraction. His apical pulse rate is 44 and he is on bed rest. After the acute phase of congestive heart failure. Bed-rest regimen D. a client with CHF. 90 g of fat and 100 g of protein. Vasodilator C. Ong. 2000 calories C. and a vasodilator drug. Diuretic B. The nurse understands that this diet contains approximately: A. 144. decreases the conduction speed of impulses within the myocardium and slows the heart rate. a diuretic. Sodium C. Mr. Magnesium B. 2800 calories D. the nurse should expect the dietary management of the client to include the restriction of: A. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates. Calcium Answer: (B) Sodium Restriction of sodium reduces the amount of water retention that reduces the cardiac workload . 1600 calories Answer: (B) 2000 calories There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein 145. has been receiving a cardiac glycoside.
A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. His usual dietary pattern D. B. Increasing HCO3 B. Decreasing PO2 Answer: (B) Decreasing PCO2 Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis. A flexible plan according to his appetite Answer: (B) Regular meals and snacks to limit gastric discomfort Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Limited food and fluid intake when he has pain D. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is: A.146. An important etiologic clue for the nurse to explore while taking his history would be: A. Decreasing PCO2 C. 149. 3 L per day would apply approximately: . 148. such as aspirin and prednisone. the client has a nasogastric tube to low continuous suction. Three large meals large enough to supply adequate energy. Jude develops GI bleeding and is admitted to the hospital. The nurse should be aware that this pattern will alter his arterial blood gases by: A. Decreasing pH D. Because 1 L of a 5% dextrose solution contains 50 g of sugar. Mucosal irritation can lead to bleeding. He begins to hyperventilate. Any recent foreign travel C. The medications he has been taking B. irritate the stomach lining and may cause bleeding with prolonged use 147. His working patterns Answer: (A) The medications he has been taking Some medications. Following surgery. Regular meals and snacks to limit gastric discomfort C.
When putting his ankle through range of motion. the nurse must perform: A. Abduction. Thrombus formation is a danger for all postoperative clients. Emptying the drainage bag frequently B. 1000 Kilocalories Answer: (B) 600 Kilocalories Carbohydrates provide 4 kcal/ gram. Encouraging adequate fluids B. maintains urine production at a higher rate. 800 Kilocalories D. 150. The nurse can best plan to avoid this problem by: A. adduction and extension . IV fluids are started and a Foley catheter is inserted. 400 Kilocalories B. flexion. urinary infection is a potential danger.A. With an indwelling catheter. therefore 3L x 50 g/L x 4 kcal/g = 600 kcal. all of which lead to thrombus formation. Collecting a weekly urine specimen C. 600 Kilocalories C. extension and left and right rotation B. which flushes the bladder and prevents urinary stasis and possible infection 152. and external pressure against the veins. The nurse should act independently to prevent this complication by: A. hypercoagulability. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon 151. Applying elastic stockings C. Performing active-assistive leg exercises Answer: (D) Performing active-assistive leg exercises Inactivity causes venous stasis. Flexion. Maintaining the ordered hydration D. An unconscious client is admitted to the ICU. The nurse performs full range of motion on a bedridden client¶s extremities. Massaging gently the legs with lotion D. only about a third of the basal energy need. Assessing urine specific gravity Answer: (C) Maintaining the ordered hydration Promoting hydration.
and extension D. plantar flexion. because surgical trauma can cause urinary retention leading to further complications such as bleeding. The transurethral resection of the prostate is performed on a client with BPH. The nurse understands that to prevent the effects of shearing force on the skin. Maintaining patency of the cystotomy tube C. nursing care should include: A. age 62. eversion and inversion These movements include all possible range of motion for the ankle joint 153. Maintaining patency of a three-way Foley catheter for cystoclysis . Urinary drainage will be dependent on a urethral catheter for 24 hours C. A client has been in a coma for 2 months. Urinary control may be permanently lost to some degree B. 155. Changing the abdominal dressing B. Shearing forces are good contributory factors of pressure sores. supination. Rene. His ability to perform sexually will be permanently impaired Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours An indwelling urethral catheter is used. the nurse should tell the client that after surgery: A. 60 degrees D. 154. Pronation. is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). the head of the bed should be at an angle of: A. eversion and inversion Answer: (D) Dorsiflexion. As part of the preoperative teaching. the torso tends to slide and causes this phenomenon. rotation. Dorsiflexion. 45 degrees C. Following surgery.C. when the bed is at an angle greater than 30 degrees. 30 degrees B. plantar flexion. Frequency and burning on urination will last while the cystotomy tube is in place D. 90 degrees Answer: (A) 30 degrees Shearing force occurs when 2 surfaces move against each other.
Twenty-four hours after TURP surgery. Reduce bladder spasms D. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis 156. In the early postoperative period following a transurethral surgery. Observing for hemorrhage and wound infection Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis Patency of the catheter promotes bladder decompression. The nurse¶s initial action should be to: A. the retention catheter is secured to the client¶s leg causing slight traction of the inflatable balloon against the prostatic fossa. Leakage around the catheter D. This is done to: A. Irrigate the catheter with saline B. The nurse notes that the catheter drainage has stopped. which prevents distention and bleeding. Notify the physician Answer: (B) Milk the catheter tubing . Promote urinary drainage Answer: (B) Provide hemostasis The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding. 157. the client tells the nurse he has lower abdominal discomfort. Provide hemostasis C.D. Urinary retention with overflow Answer: (B) Hemorrhage After transurethral surgery. Sepsis B. Limit discomfort B. hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed. Hemorrhage C. the most common complication the nurse should observe for is: A. Following prostate surgery. 158. Remove the catheter D. Milk the catheter tubing C.
Milking the tubing will usually dislodge the plug and will not harm the client. A physician¶s order is not necessary for a nurse to check catheter patency.
159. The nurse would know that a post-TURP client understood his discharge teaching when he says ³I should:´ A. Get out of bed into a chair for several hours daily B. Call the physician if my urinary stream decreases C. Attempt to void every 3 hours when I¶m awake D. Avoid vigorous exercise for 6 months after surgery Answer: (B) Call the physician if my urinary stream decreases Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction. 160. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave¶s Disease. When assessing Lucy, the nurse would expect to find: A. Lethargy, weight gain, and forgetfulness B. Weight loss, protruding eyeballs, and lethargy C. Weight loss, exopthalmos and restlessness D. Constipation, dry skin, and weight gain Answer: (C) Weight loss, exopthalmos and restlessness Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
161. Lucy undergoes Subtotal Thyroidectomy for Grave¶s Disease. In planning for the client¶s return from the OR, the nurse would consider that in a subtotal thyroidectomy: A. The entire thyroid gland is removed B. A small part of the gland is left intact C. One parathyroid gland is also removed D. A portion of the thyroid and four parathyroids are removed Answer: (B) A small part of the gland is left intact Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
162. Before a post- thyroidectomy client returns to her room from the OR, the
nurse plans to set up emergency equipment, which should include: A. A crash cart with bed board B. A tracheostomy set and oxygen C. An airway and rebreathing mask D. Two ampules of sodium bicarbonate Answer: (B) A tracheostomy set and oxygen Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.
163. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: A. Observing for signs of tetany B. Checking her throat for swelling C. Asking her to state her name out loud D. Palpating the side of her neck for blood seepage Answer: (C) Asking her to state her name out loud If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
164. On a post-thyroidectomy client¶s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops: A. Intolerance to heat B. Dry skin and fatigue C. Progressive weight loss D. Insomnia and excitability Answer: (B) Dry skin and fatigue Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.
165. A client¶s exopthalmos continues inspite of thyroidectomy for Grave¶s Disease. The nurse teaches her how to reduce discomfort and prevent corneal
ulceration. The nurse recognizes that the client understands the teaching when she says: ³I should: A. Elevate the head of my bed at night B. Avoid moving my extra-ocular muscles C. Avoid using a sleeping mask at night D. Avoid excessive blinking Answer: (C) Avoid using a sleeping mask at night The mask may irritate or scratch the eye if the client turns and lies on it during the night.
166. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara¶s body surface that is burned is: A. 4.5% B. 9% C. 18 % D. 22.5% Answer: (D) 22.5% The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%
167. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will: A. Inhibit bacterial growth B. Relieve pain from the burn C. Prevent scar tissue formation D. Provide chemical debridement Answer: (A) Inhibit bacterial growth Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes
The nurse should set the flow to provide: A. 36 gtt/min Answer: (B) 28 gtt/min This is the correct flow rate. A client with burns on the chest has periodic episodes of dyspnea. Jane. 28 gtt/min C. a 20. She is scheduled to have a series of diagnostic studies for myasthenia gravis. 18 gtt/min B. The position that would provide for the greatest respiratory capacity would be the: A. a burn client. Be sutured in place for better adherence C. Relieve pain and promote rapid epithelialization D. Orthopneic position D. Clara. In preparing . Debride necrotic epithelium B. 170. receives a temporary heterograft (pig skin) on some of her burns. which reduces pain and provides a framework for granulation that promotes effective healing. Answer: (C) Relieve pain and promote rapid epithelialization The graft covers nerve endings. the physician orders for the client 2 liters of IV fluid to be administered q12 h. including a Tensilon test.168. Semi-fowler¶s position B. Supine position Answer: (C) Orthopneic position The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion 171. The drop factor of the tubing is 10 gtt/ml. Frequently be used concurrently with topical antimicrobials.year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 169. Sims¶ position C. 32 gtt/min D. Forty-eight hours after a burn injury. These grafts will: A.
While the dosage is being adjusted. 172. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: A. Ability to smile an to close her eyelids D. Degree of anxiety about her diagnosis C. the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: A. the nurse¶s priority intervention is to: A. Ability to chew and speak distinctly B. The Mestinon dosage is frequently changed during the first week. Facilitate psychologic adjustment C. Brief exaggeration of symptoms B. Rapid but brief symptomatic improvement D. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. primary goal should be to maintain adequate activity and prevent muscle atrophy 173. It lasts several minutes. Prolonged symptomatic improvement C. Prepare for the appearance of myasthenic crisis Answer: (C) Maintain the present muscle strength Until diagnosis is confirmed. Respiratory exchange and ability to swallow Answer: (D) Respiratory exchange and ability to swallow Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration 174. Administer the medication exactly on time .her for this procedure. The most significant initial nursing observations that need to be made about a client with myasthenia include: A. Symptomatic improvement of just the ptosis Answer: (C) Rapid but brief symptomatic improvement Tensilon acts systemically to increase muscle strength. Maintain the present muscle strength D. Develop a teaching plan B. with a peak effect in 30 seconds.
Evaluate the client¶s emotional side effects between doses Answer: (C) Evaluate the client¶s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours. the nursing action that would be most effective would be to: A. Mestinon Answer: (D) Coordinate her meal schedule with the peak effect of her medication. Administer the medication with food or mild C. Evaluate the client¶s muscle strength hourly after medication D. Mestinon Dysphagia should be minimized during peak effect of Mestinon. . begins to experience increased difficulty in swallowing. Change her diet order from soft foods to clear liquids B. Mestinon can increase her muscle strength including her ability to swallow. To prevent aspiration of food. Assess her respiratory status before and after meals D.B. the response will influence dosage levels. Helen. Coordinate her meal schedule with the peak effect of her medication. Place an emergency tracheostomy set in her room C. a client with myasthenia gravis. thereby decreasing the probability of aspiration. 175.
Vision changes, such as diplopia, nystagmus, and blurred vision are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive -- not absent. Normal pressure in the anterior chamber of the eye remains relatively constant at 20 to 25 mm Hg. subdural hematoma - A condition involving the collection of blood between the dura mater and the brain. Lichtheim's sign is the inability to speark associated with subcortical aphasia. An injury from C5 to C6 results in quadriplegia, with diaphragmatic and gross arm movemens. transsphenoidal hypophysectomy - Microsurgery in which an incision is made at the junction of the gums and upper lip. A surgical microscope is advanced and a special surgical instrument is used to excise all or part of the pituitary gland. polyneuritis - Degeneration of peripheral nerves primarily supplying the distal muscles of the extremities. It results in muscle weakness, with sensory loss and atrophy, and decreased or absent deep tendon reflexes. Decerebrate posturing, characterized by abnormal extension in the response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flacidity. Receptive aphasia = damage to temporal lobe. Damage to the parietal lobe affects the client's ability to identify special relationship with the environment. Dames to the occipital lobe affects visual association. PERRLA stands for "Pupils Equal, Round, Reactive to Light and Accommodation" audiometry - Evaluation of hearing using an audiometer. Various audiometric tests identify the lowest intensity of sound at which a client can perceive an auditory stimulus, hear different frequencies, and differentiate speech sounds. Pure tone
audiometry evaluates the ability to hear frequencies, usually ranging from 125 to 8,000 Hz, and can determine whether a hearing loss results from a problem in the middle ear, inner ear, or auditory nerve. Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. The nurse must dissolve crystallized mannitol before administering it. This is best doen by warming it in hot water and shaking the container vigorously, then allowing the solution to return to room temperature before administering it. To prevent adverse reaction, which are commmon, I.V. diazepam should be administered no faster than 5 mg/minute in an adult and should be given over at least 3 minutes in children. Presbycusis is progression hearing loss associated with aging. A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy geriatric clients and in the severity of dementia. A normal and stable ICP value is less than 15 mm Hg. Chewing is a function of cranial nerve V (Trigeminal). Swallowing is a motor function of cranial nerves IX and X. epilepsy - A group of neurologic disorders marked by uncontrolled electrical discharge from the cerebral cortex and typically manifested by seizures with clouding of consciousness. Epilepsy is most commonly of unknown cause (idiopathic) but is sometimes associated with head trauma, intracranial infection, brain tumor, vascular disturbances, intoxication, or chemical imbalance. cerebral contusion - A bruising of the brain tissue as a result of a severe blow to the head. A contusion disrupts normal nerve function in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death. The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Succinylcholine (Anectine) a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired -- for example during ECT or intubation. Cones provide daylight color vision, and their stimulation is interpreted as color. Rods are sensitive to low levels of illumination but cants discriminate color.
The sweat chloride test is used to confirm cystic fibrosis. Edrophonium (Tensilon) test confirms the diagnosis of myasthenia gravis. A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. In a steppage gait, the feet and toes rish high off the floor and then heel comes down heavily with each step. When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Nonfluent aphasia is characterized by telegraphic speech, failure to use conjunctions and pronouns and impared repetition and ability to read aloud. In global aphasia, spontaneous speech is absent or limited to a few stereotyped words; comprehension is limited to the client's name or a few words. In fluent aphasia, auditory comprehension is disturbed; speech lacks meaningful content, is unrelated to questions and includes paraphasias. The client with fluent aphasia seems unaware that speech doesnt make sense and that reading and writing are impared. In anomic aphasia, the client can't name objects, has trouble finding words and may be unable to read or write. A basilar skull fracture commonly causes only periorbital ecchymosis (racoon's eyes) and postmastoid ecchymosis (Battle's sign). Atropine sulfate is a cholinergic blocker. Lower brain stem dysfunction alters bulbar functions such as breathing, talking, swallowing and coughing.
SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene. 1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is A. Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance. B. Leave the person for a few moments to call for help. C. Reduce the fracture manually. D. Move the person to a safer place. 2. Arthur suspects a hip fracture when he noticed that the old woman¶s leg is A. Lengthened, Abducted and Internally Rotated. B. Shortened, Abducted and Externally Rotated. C. Shortened, Adducted and Internally Rotated. D. Shortened, Adducted and Externally Rotated. 3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to A. Infection B. Thrombophlebitis C. Inflammation D. Degenerative disease 4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except A. Hypothyroidism B. End stage renal disease C. Cushing¶s Disease D. Taking Furosemide and Phenytoin. 5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms? A. Tachycardia and Hypotension B. Fever and Bradycardia C. Bradycardia and Hypertension
because only his right leg is weak. Rojas to hold the cane A. he came back to the emergency room of the hospital because he suffered a mild stroke. a 40 year old construction worker developed cough. Rojas to hold the cane A. On his left hand. Rojas has a weakness on his right leg due to self immobilization and guarding. The right side of the brain was affected. you observe Mr. to support the right leg. 7. An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. He told the nurse he did not receive a BCG vaccine during childhood 9. The nurse knows that Mantoux Test is also known as A. Moves the cane when the right leg is moved. SITUATION: Alfred. 1 Inches in front of the foot. B. 6. On his left hand. Rojas was discharged and 6 months later. As a nurse. B. The nurse performs a Mantoux Test. D. Rojas use a cane and you intervene if you see him A. PDP C. PPD B. You plan to teach Mr. At the rehabilitative phase of your nursing care. 3 Inches at the lateral side of the foot. Mr. B. Fever and Hypertension SITUATION: Mr. D. PDD D. Holds the cane on the right side. Leans on the cane when the right leg swings through. Rojas how to use a cane. keeps the cane 6 Inches out to the side of the right foot. On his right hand. The diagnosis was Osteoarthritis. C. c. because his right side is weak. 8. 6 Inches at the lateral side of the foot. He was brought to the nursing unit for diagnostic studies. The nurse would inject the solution in what route? . because of reciprocal motion. On his right hand. night sweats and fever. Mr. D. 12 Inches at the lateral side of the foot.D. You also told Mr. D. C. you instructed Mr. DPP 10. Rojas.
What should be the nurse¶s next action? A. for CXR evaluation C. Almost all Filipinos will test positive for Mantoux Test 15. The test result read POSITIVE. It requires a highly skilled nurse to perform a Mantoux test B. IV C. 48 hours C. III D. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions C. Mang Alfred returns after the Mantoux Test. Mang Alfred is now a new TB patient with an active disease. 10 mm Induration 12. 1 day D. Order for a sputum exam 14. Why is Mantoux test not routinely done in the Philippines? A. 5 mm Induration C. IV . Notify the radiology dept. Call the Physician B. II C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions D.A. What is his category according to the DOH? A. 10 mm Wheal D. 4 days 13. I B. 5 mm wheal B. a week B. The nurse told Alfred to come back after A. Isolate the patient D. IM B. ID D. The nurse notes that a positive result for Alfred is A. SC 11.
Undernourished and Underweight individual who undergone gastrectomy 21. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except A. Secondary C. National Tuberculosis Control Program C. 23 Year old athlete taking illegal drugs and abusing substances D. How long is the duration of the maintenance phase of his treatment? A. 2 months B. Pyridoxine 18. Primary B.16. Rifampicin B. Short Coursed Chemotherapy D. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase? A. Isoniazid C. 1-2 months after D. According to the DOH. 2-4 weeks after 19. 6-12 months after B. DOTS B. 3-6 months after C. 3 months C. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention? A. Ethambutol D. 23 Year old athlete taking long term Decadron therapy and anabolic steroids C. Expanded Program for Immunization 20. This is the name of the program of the DOH to control TB in the country A. Tertiary . 23 Year old athlete with diabetes insipidus B. 4 months D. 5 months 17. the most hazardous period for development of clinical disease is during the first A.
which of the following item indicates that the nurse needs further instruction? A. 22. Ask to defer colostomy care to another individual B. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy? A. K-Y Jelly C. The nurse should insert the colostomy tube for irrigation at approximately A. As the nurse prepares the materials needed. 12-18 inches 25. 6-8 inches D. Agrees to look at the colostomy D. Talk about his ostomy openly to the nurse and friends 23. 5 inches B. Tap water D. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following? A. Irrigation sleeve 24. Ask for leaflets and contact numbers of ostomy support groups D. 18 inches D.D. States that colostomy care is the function of the nurse while he is in the hospital . 1-2 inches B. Plain NSS / Normal Saline B. A male patient diagnosed with colon cancer was newly put in colostomy. Participate with the nurse in his daily ostomy care C. The maximum height of irrigation solution for colostomy is A. Promises he will begin to listen the next day C. 12 inches C. The nurse plans to teach Michiel about colostomy irrigation. 24 inches 26. 3-4 inches C. Quarterly SITUATION: Michiel. Look at the ostomy site B.
the nurse would A. A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema. Insert the cone 4 cm in the stoma D. Which of the following. Eat broccoli and spinach 30. The nurse knew that the normal color of Michiel¶s stoma should be A. the nurse will assess Michiel¶s stoma. Notify the physician 28. Wilma. The next day. If cramping occurs.000 ml NSS B. Eat beet greens and parsley D. slow the irrigation 31. Suspend the irrigant 45 cm above the stoma C. Michiel asked the nurse. Tell the client that cramping will subside and is normal D. Use 500 ml to 1. While irrigating the client¶s colostomy. A sunken and hidden stoma B. Eat cucumbers C. Initially. Eat eggs B.27. if made by Wilma indicates that she is committing an error? . Michiel suddenly complains of severe cramping. 32. Which of the following should be included in the nurse¶s teaching plan? A. Protruding stoma with swollen appearance 29. Blue D. Slow down the irrigation C. Pale Pink SITUATION: James. The nurse best response would be A. what foods will help lessen the odor of his colostomy. Stop the irrigation by clamping the tube B. Brick Red B. The nurse will start to teach Michiel about the techniques for colostomy irrigation. A narrow and flattened stoma D. A dusky and bluish stoma C. Gray C. His sister and a nurse is suctioning the tracheostomy tube of James. The nurse noticed that a prolapsed stoma is evident if she sees which of the following? A.
Instilling 3 to 5 ml normal saline to loosen up secretion C. Hyperventilating James with 100% oxygen before and after suctioning B. 50-95 mmHg B. 18 34. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed? A. Wilma is using a portable suction unit at home. What size of suction catheter would Wilma use for James. Fr. James¶ neck veins are not engorged . Applying suction during catheter withdrawal D. What are the 2 equipment¶s at james¶ bedside that could help Wilma deal with this situation? A. Fr. 12 D.A. Fr. Wilma was shocked to see that the Tracheostomy was dislodged. 95-110 mmHg C. 10 C. 155-175 mmHg 36. 5-10 mmHg C. 2-5 mmHg B. Theophylline and Epinephrine C. Both the inner and outer cannulas was removed and left hanging on James¶ neck. The tracheotomy can be pulled slightly away from the neck C. 10-15 mmHg D. Suction the client every hour 33. 20-25 mmHg 35. Sterile saline dressing 37. What is the amount of suction required by James using this unit? A. Fr. 100-120 mmHg D. Wilma places 2 fingers between the tie and neck B. If a Wall unit is used. Obturator and Kelly clamp D. 5 B. What should be the suctioning pressure required by James? A. who is 6 feet 5 inches in height and weighing approximately 145 lbs? A. New set of tracheostomy tubes and Oxygen tank B.
He is being seen by Nurse Jet. Obstruction in trabecular meshwork C. Measures the Intra Ocular Pressure C. James¶ Oxygen saturation is 91% C. 43. Irreversible vision loss C. Loss of peripheral vision B. 10 seconds B.D. There are moderate amount of tracheobronchial secretions 39. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process. The Nurse notices that Mr. Gradual increase of IOP D. 30 seconds D. 45 seconds SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. 38. Wilma knew that James have an adequate respiratory condition if she notices that A. Batumbakal. There is an increase in IOP D. Wilma knew that the maximum time when suctioning James is A. An abrupt rise in IOP from 8 to 15 mmHg 42. Nurse jet knew that Acute close angle glaucoma is caused by A. Sudden blockage of the anterior angle by the base of the iris B. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma? A. Determines the Tone of the eye in response to the sudden increase in IOP. Nurse jet performed a TONOMETRY test to Mr. Batumbakal cannot anymore determine RED from BLUE. 40. It measures the peripheral vision remaining on the client B. . James¶ respiratory rate is 18 B. 20 seconds C. What does this test measures A. Pain 41. There are frank blood suction from the tube D. Measures the Client¶s Visual Acuity D.
Reduce production of Aquesous Humor C. CONES [RETINA] 44. Batumbakal¶s CN II Function. Dilate the pupils D. 2-7 mmHg c. The Doctor orders pilocarpine. Contract the Ciliary muscle B. Relaxes the Ciliary muscle 49. When caring for Mr. Nurse Jet knows that Aqueous Humor is produce where? A. PUPIL c. In the Choroids D. Relax the Ciliary muscle C. Decrease production of Aqueous Humor 48. Reduce production of CSF B. Nurse jet knows that the action of this drug is A. In the Ciliary Body 45. Gonioscopy 47. Jet teaches the client to avoid . Slit lamp B. Nurse jet knows that the action of this drug is to A. Constrict the pupil D. Nurse Jet knows that the normal IOP is A. 8-21 mmHg B. 15-30 mmHg 46. Snellen¶s Chart C. 31-35 mmHg D. Batumbakal. In the Lateral ventricles C. Wood¶s light D. RODS [RETINA] D. Nurse Jet wants to measure Mr.The nurse knew that which part of the eye is affected by this change? A. The doctor orders timolol [timoptic]. IRIS B. What test would Nurse Jet implement to measure CN II¶s Acuity? A. In the sub arachnoid space of the meninges B.
Going out in the sun 50. 52. Batumbakal is receiving pilocarpine. Pindolol [Visken] C. Reading newsprint B. What activity is contraindicated immediately after procedure? A. Lying down C. After instilling a warm water in the ear. Bending at the waist C. Normal D. What does this means? A. If Mr. Inconclusive 53. Pull the pinna up and back and direct the solution onto the wall of the canal . Anna noticed a rotary nystagmus towards the irrigated ear. Mesoridazine Besylate [Serentil] SITUATION : Wide knowledge about the human ear. Atropine Sulfate B. Watching large screen TVs B. Pull the pinna down and back and direct the solution towards the eardrum D. Watching TV D. Indicates a CN VIII Dysfunction B. The most appropriate method to administer the ear drops is A. Listening to the music 51. Nurse Anna is doing a caloric testing to his patient. it¶s parts and it¶s functions will help a nurse assess and analyze changes in the adult client¶s health. Reading books D. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. Ear drops are prescribed to an infant. Pull the pinna up and back and direct the solution towards the eardrum B. Mr. Aida. Abnormal C. Pull the pinna down and back and direct the solution onto the wall of the canal C. a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark.A. Naloxone Hydrochloride [Narcan] D. what drug should always be available in any case systemic toxicity occurs? A.
CN I B. Diet and Nutrition D. Steven into the hospital admission. Nurse Anna is giving dietary instruction to a client with Menieres disease. which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions? . Which of the following should the nurse question? A. Nurse Jenny is developing a plan of care for a patient with Menieres disease. Dipenhydramine [Benadryl] B. I will try to eat foods that are low in sodium and limit my fluid intake B. What is the priority nursing intervention in the plan of care for this particular patient? A. Safety 55. I must drink atleast 3. Use a flashlight to coax the insect out of peachy¶s ear B. Instill an antibiotic ear drops C. Pick out the insect using a sterile clean forceps 59. Food. Air. I will try to follow a 50% carbohydrate.000 ml of fluids per day C. After mastoidectomy. Love and Belongingness C. red meat and raddish 58. Breathing. Which statement if made by the client indicates that the teaching has been successful? A. Out of bed activities and ambulation D. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. Peachy was rushed by his father. The physician orders the following for the client with Menieres disease. Atropine sulfate C. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy¶s ear? A. CN II C. Nurse John should be aware that the cranial nerve that is usually damage after this procedure is A. CN VII D. Diazepam [Valium] 57. 30% fat and 20% protein diet D. I will not eat turnips. CN VI 56. Irrigate the ear D.54. Following an ear surgery. Circulation B.
Which of the following is a correct conclusion for nurse Josph to make? A. Body Image disturbance R/T the eye packing after surgery 62.A. What does this finding indicates? A. low sodium and high calorie intake D. He might have a conductive hearing loss in the right ear. and/or a sensory hearing loss in the left ear. I will use straw for drinking D. Nurse Oca is preparing plan of care. and/or a conductive hearing loss in the left ear. high protein dietary intake C. I should avoid air travel for a while 60. This indicates an intact and working vestibular branch of CN VIII 61. A low sodium . Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient? A. low sodium and restricted fluid intake . I will make sure that I will clean my hair and face to prevent infection C. 63. Conductive hearing loss is possible in the right ear C. A high calorie. Aling myrna has Menieres disease. low fat. Activities are resumed within 5 days B. What typical dietary prescription would nurse Oca expect the doctor to prescribe? A. Knowledge deficit R/T the pre operative and post operative self care D. He placed the tuning fork in the patients forehead after tapping it onto his knee. high fluid intake B. The client states that the fork is louder in the LEFT EAR. He instilled a cold water in the client¶s right ear and he noticed that nystagmus occurred towards the left ear. Anxiety R/T to the operation and its outcome B. Indicating a Cranial Nerve VIII Dysfunction B. This is Grossly abnormal and should be reported to the neurosurgeon D. A client with Cataract is about to undergo surgery. The test should be repeated again because the result is vague C. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. D. Sensory perceptual alteration R/T Lens extraction and replacement C. He might have a sensory hearing loss in the right hear. Nurse Joseph is performing a WEBERS TEST. He might have a sensory hearing loss in the left ear B.
Frequent oral care D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting 67. Assessment disclosed: weak rapid pulse. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting D.5kg. 750 ml C. Which of the following measures will not help correct the patient¶s condition A. Postural Hypotension is A. Temperature: 35. you will expect the patient to have 1. 50 ml B. Dehydration R/T incessant vomiting 65. He also complains for postural hypotension. Which of the following is the appropriate nursing diagnosis? A. B. 500 ml D. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting C.SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting.5 C . Dehydration R/T subnormal body temperature D. There was no infection. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting. Offer large amount of oral fluid intake to replace fluid lost B. 64. slow flattening of the skin was noted when the nurse released her pinch. 75 ml 66. Approximately how much fluid is lost in acute weight loss of . furrows in his tongue.5kg? A. BUN Creatinine ratio : 10 : 1. Give small volumes of fluid at frequent interval 68.8 C . acute weight loss of . Fluid volume deficit R/T furrow tongue B. Maintain body temperature at 36. After nursing intervention. Fluid volume deficit R/T uncontrolled vomiting C. Give enteral or parenteral fluid C.
The patient was prescribed with levodopa. the patient complained of difficulty in walking. Release dopamine and other catecholamine from neurological storage sites 72. One day. 1. Vitamin E rich food C.3.2. Activates dopaminergic receptors in the basal ganglia C. Disturbed vision B. Drinks fluids as prescribed A. Thiamine rich food D. 1. Which of the following is a characteristic of a patient with advanced Parkinson¶s disease? A. Impairment of dopamine producing cells in the brain 71. 69. Hereditary factors C. Increase dopamine availability B. Manifest normal skin turgor of skin and tongue 4.3. The charge nurse is going to make an initial assessment. Forgetfulness C.4 C. Injurious chemical substances B. Mask like facial expression D. You are discussing with the dietician what food to avoid with patients taking levodopa? A. Exhibit return of BP and Pulse to normal 3.3 B. 2. This disorder is caused by A. Vitamin B6 rich food 73. Decrease acetylcholine availability D.4 SITUATION: A 65 year old woman was admitted for Parkinson¶s Disease. Your response would be . Death of brain cells due to old age D. Vitamin C rich food B. The onset of Parkinson¶s disease is between 50-60 years old.4 D. 2. What is the action of this drug? A. Muscle atrophy 70.
74. Agnosia D. Relaxation technique . which of the following statement of the daughter will require the nurse to give further teaching? A. Judgment C. Use a medium-pitched voice 77. the nurse will A. Balance B. Speech D. Aphraxia C. Walk erect with eyes on horizon C. You will need a cane for support B. Don¶t force yourself to walk SITUATION: Mr. Drug Compliance C.A. Ill turn off the TV when we go to another room 78. Open mouth wide while talking to the client C. Which of the following is most important discharge teaching for Mr. a client with early Dementia exhibits thought process disturbances. The nurse will assess a loss of ability in which of the following areas? A. Endurance 75. Dela Isla said he cannot comprehend what the nurse was saying. Dela Isla. The nurse is aware that in communicating with an elderly client. I help her do some tasks he cannot do for himself D. Dela Isla. I know the hallucinations are parts of the disease B. Aphasia 76. Emergency Numbers B. I¶ll get you a wheelchair D. Dela Isla A. He suffers from: A. Lean and shout at the ear of the client B. I told her she is wrong and I explained to her what is right C. As the nurse talks to the daughter of Mr. Use a low-pitched voice D. Insomnia B. Mr.
Take the drug on empty stomach C. Stimulate peristalsis for treatment of constipation and obstruction 80. Increases glandular secretion for clients affected with cystic fibrosis B. Take with a full glass of water in treatment of Ulcerative colitis D. Avoid hazardous activities like driving. Dissolve blockage of the urinary tract due to obstruction of cystine stones C. NSAID C. Franco. Reduces secretion of the glandular organ of the body D. Alcohol 82. Make sure you limit your fluid intake to 1L a day D. What should the nurse caution the client when using this medication A. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? A. He was rushed to the hospital unconscious. Caffeine B. What is the action of this drug? A. B. What should the nurse tell clients when taking Probanthine? A. His diagnosis was CVA. Ulcerative Colitis D.D. I must take double dose if I missed the previous dose 81. Never swim on a chlorinated pool C. Avoid hot weathers to prevent heat strokes B. Glaucoma SITUATION : Mr. Dietary prescription SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders. 79. 70 years old. suddenly could not lift his spoons nor speak at breakfast. Acetaminophen D. . Urinary retention B. operating machineries etc. Which of the following drugs are not compatible when taking Probanthine? A. Peptic Ulcer Disease C. Avoid cold weathers to prevent hypothermia 83.
What is the rationale for giving Mr. If Mr. which of the following is most important to include in preparing Franco¶s bedside equipment? A. 87. Expressive aphasia is prominent on clients with right sided weakness B. He will be thirsty considering that he is doesn¶t drink enough fluids B. . Mouth breathing is used by comatose patient and it¶ll cause oral mucosa dying and cracking.84. Suction machine and gloves 86. Franco? A. The affected lobe in the patient is the Right lobe C. The tactile stimulation during mouth care will hasten return to consciousness D. Keep skin clean and dry 88. Franco frequent mouth care? A. Hand bell and extra bed linen B. Coherence and sense of hearing D. Patency of airway and adequacy of respiration 85. Use special water mattress D. Which of the following can best prevent its occurrence? A. Blood test was ordered. Footboard and splint D. Diagnosis is acute appendicitis. Upon palpation of his abdomen. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. The client will have problems in judging distance and proprioception D. Sandbag and trochanter rolls C. To remove dried blood when tongue is bitten during a seizure C. Level of awareness and response to pain B. Franco¶s conditions. Clients orientation to time and space will be much affected SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Turn frequently every 2 hours C. What should be the most accurate analysis by the nurse? A. Ernie jerks even on slight pressure. One of the complications of prolonged bed rest is decubitus ulcer. Massage reddened areas with lotion or oils B. Considering Mr. Complained of severe right iliac pain. Franco¶s Right side is weak. Papillary reflexes and response to sensory stimuli C.
Hgb : 13 to 14 gm/dl. Peritonitis may occur in ruptured appendix and may cause serious problems which are 1. electrolyte imbalance Elevated temperature. 3. Consent signed by the father B. D. Post op care for appendectomy include the following except A. General C. Hypnosis 93. Spinal B. B.000/cu. weakness and diaphoresis Nausea and vomiting. RBC : 4. Allay anxiety and apprehension B. Diet as tolerated after fully conscious C. Prevent vomiting D. C.5 TO 5 Million / cu.000 to 500. Remove the jewelries 91. 2. 4. Nasogastric tube connect to suction D. WBC : 12.mm. Which result of the lab test will be significant to the diagnosis? A.000 to 13. Hypovolemia. Deep breathing and leg exercise 94. Platelets : 250. Skin prep of the area including the pubis D. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to : A. Pre op care would include all of the following except? A. Early ambulation B. Relax abdominal muscle 92.000 cu. mm. Stat appendectomy was indicated. Reduce pain C. Caudal D.89. rigidity of the abdominal wall Pallor and eventually shock . Common anesthesia for appendectomy is A. Enema STAT C.mm 90.
Organic Psychoses 99. 1. Offer some ice chips to wet lips 97. Inorganic Psychoses C. Occurs suddenly and reversible B. 98. In caring for the patient with NGT. Use sterile technique in irrigating the tube C.A. Inorganic Stroke B. When patient requests for it B. Ruptured colon 96.2. and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home. Abdomen is soft and flatus has been expelled D. NGT was connected to suction. Abdomen is soft and patient asks for water C. 2 and 3 C. what would be the most suspected complication? A.3 D. B and C only Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital. Is progressive and reversible . Irrigate the tube with saline as ordered B. Organic Stroke D. 1 and 2 B. All of the above 95. advance the tube every hour to avoid kinks D. The main difference between chronic and organic brain syndrome is that the former A. Paralytic Ileus C. the nurse must A. What do you call a STROKE that manifests a bizarre behavior? A. Hemorrhage D. If after surgery the patient¶s abdomen becomes distended and no bowel sounds appreciated. Intussusception B. When do you think the NGT tube be removed? A.
Occurs suddenly and irreversible 100. Which behavior results from organic psychoses? A. Disorientation C. Memory deficit B. tends to be progressive and irreversible D. Impaired Judgement D. Inappropriate affect .C.
Extension of upper extremities. plantar flexion of feet. 1. Block beta stimulation in the heart d. On the lower abdomen b. Pregnancy d. a. Flexion of both upper and lower extremities b. Diabetes b. Flexion of elbows. Act as a vasoconstrictor b. Under the thigh d. The desired effect of this drug is to. Act as a vasodilator c. Preparing for an intravenous pyelosram (IVP). On the inner thigh 5.The physician orders propranolol (Inderal) for a client's angina. A client with alcoholic cirrhosis with ascites and portal hypertension is to receive neomydn. the condition that will eyclude this client from Coumadin therapy is: a. Sterilize the bowel b. the nurse will observe: a.Situation 1: A nurse who is assigned in a medical ward took time to be prepared with her task and give quality nursing care. Decrease the serum ammonia d. Extension of elbows and knees. Prevent infection 4. The effect of this drug is to: a. and plantar flexion of the feet d. A retention catheter for a male client is correctly taped if it is: a. When assessing a client for Cournadin therapy. If a client with increased pressure (ICP) demonstrates decorticate posturing. the nurse instructs a 25- . and flexion of the wnsts c. Increase the heart rate 3. Arthritis c. On the umbilicus c. Reduce abdominal distention c. extension of the knees. flexion of lower extremities 2. Peptic ulcer disease 6.
Respiratory acidosis b. If a client continues to hypoventilate. the next action is to: a. Use of stimulants such as tobacco d. Connect the catheter into the drainage tubing c. Immediately following a thoracentesis. The nurse is collecting a urine specimen from a client who has been catheterized. Metabolic acidosis d. Metabolic alkalosis Situation 2: Diabetes Meilitus is a common disease among Filipinos. Serosanguimeous drainage from the puncture site b increased temperature and blood pressure c. Use of any medications 7. the nurse will continually assess for a complication of this condition. a. Inflate the catheter balloon with sterile water b. When the urine begins to flow through ths catheter.year-old male client to restrict her: a. Hypotension and hypothermia 8. the nurse must use: a. Caring for these patients require meticulous assessment and follow-up. Sterile equipment and maintain medical asepsis d. Respiratory alkalosis c. increased pulse and pallor d. Physical activity c. Fluid intake b. During a retention catheter insertion or bladder irrigation. Sterils equipment and wear sterile gloves b. . Clean equipment and technique 10. which clinical manifestations indicate that a complication has occurred and the physician should be notified? a. Place the catheter tip into the specimen container c. Place the catheter tip into the urine collection receptacle 9. Clean equipment and maintain surgical asepsis c.
Exercise stimulates pancreatic insulin production c. The pancreas utilizes more glucose during exercise 12. The statement that indicates the diabetic has an understanding of the purpose of these food lists is: a. The nurse wiiS know tills client understands if she says these symptoms are: a. acetone breath. A diabetic's muscle require more glucose during exercise d. Exchanges are allowed between groups c. Vegetables and fruit exchanges can be Interchanged 13. normal breath. Only meat and fat exchanges can be interchanged d. A person with a diagnosis of adult diabetes (NIDDM) should understand the symptoms of a hyperglycemic reaction. poiyuria and decreased appetite b. and increased thirst c. Reduces insulin binding at receptor cites d. Simple carbohydrates c. The nurse will know the client understands the diet when he says that when he consumes alcohol.11. The diabetic client the nurse is counseling is a young man who occasionally goes drinking with his buddies. Reduces the number of insulin receptors b. The non-insulin-dependent diabetic who is obese is best controlled by weight loss because obesity a. Weight gain. Exchanges are allowed within groups b. Reduces pancreatic insulin production 14. and thirst 15. Flushed cheeks. vomiting and diarrhea d. Nausea. Complex carbohydrates . Protein b. Cause pancreatic islet cell exhaustion c. Exercise enhances the passage of glucose Into muscle celts b. Thirst. or juice or fruit during exercise activity because a. The nurse will know a diabetic client understands exercise and its relation to glucose when he says that he eats bread and milk before. he includes il as part of: a. The ADA exchange diet is compiled of lists of foods.
The nurse recognizes that the teaching was effective when the client says. Not influenced by drugs 18." c. Skim milk 17. "Control my diabetes through diet. Grapefruit juice d. Fats b. Tomato c. Done by the cient d. The nurse understands that the elevated ketone level present with this disorder is caused by the incomplete oxidation of: a. I should: a. Lettuce b. which is based on the exchange system. b." .A client is diagnosed as having non-insulin-dependent diabetes mellitus how to provide self-care to prevent infections of the feet. and medication. A client with insulin-dependent diabetes is pjaced on an insulin pump. Fats 16. The most appropriate short-term goal in teaching this client to control the diabetes: " The client will: a. Potassium d. The nurse wiil know the dient has learned correctiy when she says that she can have as much as she wants of: a. "Massage my feet and feet with oil or lotion. More accurate .d." d." 19. A client is admitted to the hospital with diabetic ketoadosis. "Eat foods high in kilocalories of protein and carbohydrates. "Apply heat intermittently to my feet and legs. exercise." b. Easier to perform c. Carbohydrates 20. Protein c. The nurse should evpiain to a dient with diabetes meliitus that selfmonitoring of blood glucose is preferred to urine glucose testing because it is: a. The nurse is teaching a Type 1 diabetic client about her diet. Adhere to the medical regimen.
lateral to the trachea d. Decrease the amount of fat-binding fiber d.b." d. should teach the client to: a. the nurse. in discussing dietary guidelines. Associated with wheezing and coughing 25. At the base of the neck". A result of left ventricular failure c. Flushed face 24. Fatigue b. A client who has been admitted to the cardiac care unit with myocardial infarction complains of chest pain. In the lateral neck region b. A result of right ventricular failure d.watched out. The nurse would expect a client diagnosed as having hypertension to report experiencing the most common symptom associated with this disorder. Increase the ratio of complex carbohydrates 23. Remain normogtycemic for 3 weeks. Avoid eating between meals b. the nurse should palpate: a. At the anterior necK. Nosebleeds d. To help reduce a client's risk factors for a heart disease. the nurse has a patient who needs to be. Headache c." c. The nursing intervention that would be most effective in relieving the client's pain would be to administer the . Decrease the amount of uhsaturated fat c. a. A client with a history of hypertension develops pedal edema and demonstrates dyspnea on exertion. The nurse recognizes that the client's dyspnea on exertion is probably. Caused by cor pulmonale b. Demonstrate the correct use of the insulin pump. 21. Immediately below the mandible c." Situation 3: In the CCU. List three self-care activities necessary to control the diabetes. along the clavicle 22. which is: a. To determine the status of a clients carotid pulse.
Dilates coronary blood vessels b. When assessing a client with a diagnosis of left ventricular failure (congestive heart failure). Helps prevent fibrillation of the heart d. Crushing chest pain b. Morphine sulfate 2 mg IV b. Tachycardia 30. Dyspnea on exertion . a. Rapid vasodilation of the coronary arteries 27. Compression of the heart muscle b. the nurse should expect to find: a. The nurse recognizes that a pacemaker is indicated when a client is experiencing. Oxygen per nasal cannula c. Lidocaine hydrochloride 50 mg IV bolus 26. Several days following surgery a client develops pyrexia. Dyspnea b. Relieve pain and prevents shock c. The nurse should monitor the client for other adaptations related to the pyrexia including: a. Decreases anxiety and restlessness 28. Nitroglycerine sublingually d. The nurse admitting a client with a myocardial Infarction to ICU understands that the pain the client is experiencing is a result of: a. Chest pain c. Heart block d. a. Angina b. A male client who is hospitalized following a myocardial infarction asks the nurse why he is receiving morphine. The nurse replies that morphine. Chest pain c. Release of myocardia! isoenzymes c. Elevated blood pressure 29.ordered: a. Inadequate perfusion of the myocardium d. Increased pulse rate d.
Confusion c. a. The expected outcome of this treatment will be a decrease in: .minute period d. When monitoring for hypernatremia. 3650 ml d. Pulse rates of 120 and 110 in a 15. After a Whippie procedure for cancer of the pancreas. 1500 ml D5NS. Serum albumin Is to be administered intravenously to client with ascites. The dietary practice that will help a client reduce the dietary intake of sodium is a. Avoiding the use of carbonated beverages d. 31. the nurse should be able to understand the calculations and other conditions related to loss or retention. 3150ml b.5 liter normal saline. Pale coloring 35. Central venous pressure reading of 2 cm H20 c. Using an artificial sweetener in coffee c. Urinary output of 30 ml in an hour b. Jugular vein distention d. Using catsup for cooking and flavoring foods 33. Tachycardia d. 1000 ml D5W. Dry skin b. Increasing the use of dairy products b. the nurse should assess the client for: a. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes 34. 3750ml 32. a client is to receive the following intravenous (IV) fluids over 24 hours.c. When evaluating a client's response to fluid replacement therapy. 3200 ml c. Extensive peripheral edema Situation 4: In the recall of the fluids and electrolytes. 0. an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. the observation that indicates adequate tissue perfusion to vital organ is. The nurse calculates that the clients IV fluid intake Tor 24 hours will be: a. In addition.
b. The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of: a. To administer the .a. Blood pressure every 15 minutes d. A glass of water every hour until hydrated b. a. A rapid IV infusion of an electrolyte and glucose solution 37. Respiratory congestion d. Small frequent intake of juices. A client with ascites has a paracentesis. The IV tubing has a drop factor of 15 gtt/ml. Urinary output b. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-thickness burns to the trunk and right thigh. and 1500 ml of fluid is removed. Diffusion c. A rapid. c. Decreased peristalsis . or milk c. Osmosis d. An increased in temperature 39. would be aware that the most significant data would be obtained from recording a. Abdominal girth c.The nurse. Urinary output every hour c. Weights every day . Filtration b. Serum ammonia level d. A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. Extent of peripheral edema every 4 hours 38. Short-term NG replacement of fluids and nutrients d. The nurse should anticipate that the physician will order. broth. Hepatic encephalopathy 36. thready pulse b. Active Transport 40. Immediately following the procedure it is most important for the nurse to observe for: a.
32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity. Positive ELISA and Western blot tests c. Uses a'condom each time there is a sexual intercourse 44. To assess possible causes for the fever. a. "Have you been exposed recently to anyone with an infection?" d. a.A client comes to the clinic complaining of weight loss. Obtain vita! signs b. Halfway through the administration of a unit of blood. 16 gtt/min c. a. Stop the transfusion c. The nurse should: a. "Have you bee sexually active lately?" b. Increase the flow of normal saline 42. Identification of an associated opportunistic infection . Makes a donation of a pint of whole blood c. "Do you have a sore throat at the present time?" c. fatigue. it would be most appropriate for the nurse to initially ask: a. 29 gtt/min d. The knows that a positive diagnosis for HIV infection is made based on. Assess the pain further d. 41. and a lowgrade fever. a client complains of lumbar pain. 13 gtt/min b. Physical examination reveals a slight enlargement of the cervical lymph nodes. Has intercourse with just the spouse b. Limits sexual contact to those without HIV antibodies d. Evidence of extreme weight loss and high fever d. "When did you first notice that your temperature had gone up?" 43. The discussion reveals that an individual has no risk of exposure to HIV when that individual.required fluids the nurse should set the drip rate at. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). A history of high-risk sexual behaviors b.
Avoid traumatic injuries and exposure to any infection c. Determine whether the client has allergies b. . Monitor Intake and output of fluids d. The nurse should instruct the client to make an appointment so the test can be read in: a. Wear a mask and gown d. Begin a program of aggressive. Report any unusual muscle cramps or tingling sensations in the extremities 47. Use barrier techniques c. Increase dally intake of fluids c. The nurse should. Obtain the results of the culture and sensitivity tests 50. a. a. the nurse should. a. When taking the blood pressure of a client who has AIDS the nurse must. increase oral fluid intake to a minimum of 3000 ml daily d. a client has an anaphylactic reaction. A tuberculin skin test with purified protein derivative (PP!) tuberculin is performed as part of a routine physical examination. moist dressing over the area c. Apply a warm.45. Use a soft toothbrush for oral hygiene 48. strict mouth care b. 3 days b. Monitor for signs of alopecia b. The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to. Measure the amount of swelling in the client's leg d. Following multiple bee stings. a.A client is admitted with cellulites of the left teg a temperature of 103°F. An elderly client develops severe bone barrow depression from chemotheraphy for cancer of the prostate. The physician orders IV antibiotics. The nurse is aware that the symptoms the client is experiencing are caused by. 5 days c. 10 days 49. Before instituting this therapy. Wear dean gloves b. 7 days d. Wash the hands thoroughly 46.
Administration of Vallum 4 mg with 4 oz water 1 hour before surgery. Atelectasis due to shallow breathing d. Stimulates decreased gastric secretion. b. d. Mangoni's physical discussed possible therapies with him. 52. c. Respiratory depression and cardiac standstill b.a. Mangoni asks why the vagotomy is being done. It after 6 hours b. Urinary retention due to prolonged use of antichoiinergic medications. Mr. Constriction of capillaries and decreased peripheral circulation Situation 6: Following these diagnostic tests. b. c. Abdominal distention due to air swallowing c. and gastrojejunostomy would be performed. thereby increasing nausea and vomiting. It continued for a period greater than 12 hours. 54. It was dark red in the immediate postoperative period. c. Mangoni's postoperative period? a. Instructions to avoid taking pain medication too frequently in the first 2 postoperative days to avoid drug dependency. 51. You explain that a vagotomy is done in conjunction with a subtotal gastrectomy because the vagus nerve: a. would you primarily anticipate in Mr. It was decided that a partial gastrectomy. b. d. Stimulates increased gastric motility. Detailed description of the possible complications that could happen postoperatively d. Thrombophlebitis from decreased mobility. Which of the following nursing interventions would be included. The nurse would recognize drainage from the nasogastric tube after surgery as abnormal If: a. Decreased cardiac out and dilation of major biood vessels d. bronchial constriction and decreased peripheral resistance c. . Insertion of a nasogastric tube on the morning of surgery. Decreases gastric motiiity. Mr. 53. Which of the following complications. vagotomy. in the preoperative period for Mr. Stimulates both increased gastric secretion and gastric motiiity. thereby preventing the movement of HCl out of the stomach. ft turned greenish yeiiow in less than 24 hours. Mangoni? a.
The nurse will usually ambulate the post gastrectomy patient beginning. pressure should be increased to complete that irrigation. Mangoni that the nasogastric tube will be removed: a. 60. which one should be used with caution when a client has a nasogastric tube? a. Thirty-six hours after the cessation of bloody drainage.can be taken as often as desired to promote comfort in the throat. The nurse must observe for which of the following imbalances to occur with prolonged nasogastric suctioning? a. b. Hyperkalemia c. The nurse tells Mr. b. When resistance is met while irrigating a nasogastric tube. Of the following mouth care measures by the nurse. Metabolic alkalosis d. Decreased hydrochloric acid production Inhibits vitamin B12 reabsorption. b. d. 56. Nasogastric tubes should be irrigated with sterile water. When bowel sounds are established and the client has passed flatus or Stool c.55. b. d. Sucking on ice chips to relieve dryness. After 2 days of alternate clamping and unclamping of the tube. which may be a problem after gastrectomy because: a. Hypoproteinemia 57. d. The intrinsic factor Is produced in the stomach. Regularly brushing teeth and tongue with soft brush. c. Ice chips. Standardly on the fourth postoperative day. Client should be in sitting position with head slightly flexed for tube Insertion c. and the physician should be notified at the completion. d. 59. . Occasionally rinsing mouth with a nonastringent substance and massaging gums. c. Following surgery the nurse must observe for signs of pernicious anemia. 58. Hypernatremia b. Application of lemon juice and glycerine swabs to the lips. The extrinsic factor is produced In the stomach. Which of the following statements would the nurse include in teaching regarding nasogastric tubes? a. The extrinsic factor is absorbed in the antral portion of the stomach.
a. or acute. silent. immediately upon awakening . glaucoma differs from close-angle. An infectious process that causes clouding and scarring of the cornea. After 4 days bedrest d. 5-10 mm Hg b. and generally painless . and vomiting. Lee was admitted to the hospital with a diagnosis of open-angle glaucoma. Halos around lights. Difficulty with close vision. d. Open-angle. c. b. 62. The day after surgery b. severe headache. 10-20 cm H20 d. 20-30 mm Hg 63. Three to four days after surgery c. . c. A degenerative disease characterized by narrowing of the arterioles of the retina and areas of ischemia. The signs and symptoms of open-angle glaucoma are related to: a. 64. Assessment of the intraocular pressure as measured by tonometry would be normal if the value is in the range. A dysfunction of aging in which the retina of the eye buckles from inadequate fluid pressures. or chronic. Situation 7: Donald Lee. While taking Mr. the nurse would be alerted to a sudden increase in intraocular pressure if he complained of. whereas closed-angle glaucoma has a slow. b. Lee's history. Open-angle glaucoma occurs less frequently than closed-angle glaucoma. An imbalance between the rats of secretion of intraocular fluids and the rate of absorption of aqueous humor. Tonometry revealed increased intraocular pressures. d. Open-angle glaucoma's symptomatology Includes pain. a. glaucoma in. nausea. increasing discomfort in the left eye with radiation to his forehead and left temple. a 70-year-old retired businessman.to his ophthalmologist wilt's complaints of decreasing peripheral vision. Client teaching about glaucoma should include a comparison of the two types. that a. Generalized decrease in peripheral vision over the past year.a. 12-22 mm Hg c. 61. Mr. went . b.
and therefore increased pupil size. d. c. d. the nurse should gently pull down the lower lid of the eye and instill the drop: a. Loss of mobility due to severe-driving restrictions b. Piiocarpine is the drug of choice in the treatment of open-angle glaucoma. Lee because activity tends to increase intraocular pressure. It does not narrow or close the angle of the anterior chamber. Decreased light and near-vision accommodation due to miotic effects of pilocarpine. Constriction of aqueous veins and therefore decreased venous pooling in the eye. c. 66. as in closed-angle glaucoma. d. To correctly instill pilocarpine in Mr. Bedrest is ordered for Mr. The expected outcome following administration would be: a. The obstruction to aqueous flow In open-angle glaucoma generally occurs somewhere in Schlemm's canal or aqueous veins. Open-angle glaucoma rarely occurs in families. Which of the following activities of daily living should he be instructed to avoid? a. b. however. Dirediy on the central surface of the cornea b. Seif-feeding d. Passive range-of-motion exercises 67. Situation 8: Gladys Meeker is a 30-year-oid advertising executive with a history of ulcerative colitis since age 22. Blocked action of cholinesterase at the cholinergic nerve endings. Impaired vision from decreased aqueous humor production. Her chief complaint is severe abdominal cramping and . Watching television b.onset. The frequent nausea and vomiting accompanying use of miotic drugs. 65. Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid. Which of the following aspects of open angle glaucoma and its medical treatment is the most frequent cause of client noncompliance? a. into the conjunctive sac d. On the inner canthus of the eye c. c. The painful insidious progression of this type of glaucoma. Directly on the dilated pupil 68. there is a heredity predisposition for closed-angle glaucoma. Lee's eyes. Brushing teeth and hair c.
20 stools per day for four days. Comparing the client's present weight with her weight on her last admission. Her oral intake of both fluids and solids was poor. b. d. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma. electrolytes as well as fluid are lost. a. Decreased hematocrit and hemoglobin c. thus reducing cellular swelling. irregular pulse. d. Kussmaul breathing. Dyspnea and crackles.Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility.18. diarrhea. What side effects from too rapid an infusion rate would the nurse expect Ms. which include: a. 70. noting any changes. 69. . Her physician ordered parenteral hyperalimentation. With severe diarrhea. c. While administering the ordered solution. c. Cellular dehydration and potassium depletion b. b. Taking her blood pressure first supine. Spasms. 71. It is important to remember that hyperalimentation solutions are: a. thirst. Administering the oral water test. Meeker to demonstrate? a. weakness. Alkalizing solutions used to treat metabolic acidosis. then sitting. furrowed tongue. Hyperosmoiar solutions used primarily to reverse negative nitrogen balance. Three days after admission Ms. The nurse would conclude that the client is experiencing hypokalemia if which of the following were observed? a. d. Circulatory overload and hypoglycemia. Hypoglycemia and hypovolemia. Measuring the quantity and speciflc gravity of her urine output b. The nurse would recognize other signs of hypovolemia. Potassium excess and congestive heart failure. Dry mucous membranes and soft eyeballs. b. Meeker continued to have frequent stools. Apathy. Decreased pulse rate and widened pulse pressure. c. 73. Blood and fluid loss from frequent diarrhea may cause hypovolemia. You can quickly assess volume depletion In Miss Meeker by. GI disturbance 72. Hypotonic solutions used primarily for hydration when hemoconcentration is present. c. d.
78. 75. The primary objective of this procedure is.Which of the goals would be described to Ms. 24 hours later. b. After the ileostomy begins to function. The client's urine should be tested for glucoseacetone every 8-12 hours. Following iieostomy. Relief of pain to promote rest and relaxation. Situation 9: After 10 days of therapy. To reduce the incidence of wound infections by decreasing the number of intestinal organisms. The hyperlimentation subclavian line may be utilized for CVP readings and/or blood withdrawal. the nurse initiates ileostomy teaching with Ms. In the operating room. d. when edema has subsided. On the morning of surgery she catheterized and nasogastric tube was inserted. Meeker's physician decided to perform an iieostomy. c. Occlusive dressings at the catheter insertion site are changed every 48 hours using the clean technique.74. Ms. Skin care and control of odors. When the client is able to begin self-care procedures. d. c. Neomycin was administered by the nurse prior to surgery: a. a. Meeker. During the early postoperative period. Meeker as the highest postoperative nursing priority? a. 77. d. . To increase the effectiveness of the body's immunologic response following surgical trauma. and nutritional balances. Records of intake and output and daily weights should be kept. b. To prevent postoperative bladder atony due to catheterization. c. Maintenance of fluid. d. . For 3 days prior to surgery she was given neomycin. b.Which of the following statements is correct regarding nursing care of Ms. Meeker while she is receiving hyperlimentation? a. c. b. Assisting the client with self-care activities. electrolyte. To decrease the incidence of postoperative atelectasis due to decreased depth of respirations. the nurse would expect the drainage appliance to be applied to the stoma. 76.
d.a. he has difficulty sleeping due to pain and fatigue after the treatments. To reduce [he risk of postoperative wound infection. Thermal stimulation b. He also expresses concern over possible loss of job and disfigurement. Clifford dreads physical therapy and resists activity. d. Altered Nutrition. b. Mechanical stimulation d. Mr. c. Ms. He lacks appetite for food or fluid. He complains of intense pain during wound cleansing. After discharge. c. NPO until vomiting stops. What would you advise? a. Call the physician if symptoms persist for 24 hours.o. Take 30 cc of m. To prevent excoriation of the skin around the stoma.m. debridement. At this. Staying with him as much as possible and building trust c. Pain related to bums. Based on this information. Situation 10: Joseph Clifford. stage. Clifford continues to experience significant pain after his expensive bum wounds have healed . b. c. the nurse can most effectively intervene for his pain by: a. Mr. and watery discharge from her iieostomy. Less Than Body Requirements related to pain secondary to bums. b. Chemical stimulation 81. Meeker calls you at the hospital to report the sudden onset of abdominal cramps. (milk of magnesia). d. his priority nursing diagnosis would be: a. Call the physician immediately. d. Menta! stimulation c. 80. and physical therapy. Sleep Pattern Disturbance reiated to pain secondary to bums. Providing distraction and guided imagery. . To facilitate maintenance of intake and output records b. 79. vomiting. Activity Intolerance related to pain secondary to bums. This pain most likely is related to: a. 82. Providing cutaneous stimulation and pharmacoiogic therapy. Referring him for his counseling and occupational therapy. To control unpleasant odors.6 months after his injury. age 38. dressing change. has extensive bums over much of his trunk and arms.
The primary focus of care in the long-term nursing care for Mrs. Eventually. He finally heeded the nurse's recommendation and sought treatment at a pain center. The patient develops increased tolerance for severe pain in the future. Psychologic factors can contribute to a patient's pain perception. 84. c. Smith. including looking for a new job. 85. Increase the RV. after which his pain subsided and he permitted his former fiancee to participate in his rehabilitation process. has been diagnosed with COPD. Pain sensation is affected by a patient's anticipation of pain. she is presently in stable condition. b. Providing cutaneous stimulation Situation 11: Mrs. d. Which of the following statements regarding pain is incorrect? a. 86. c.83. Increase the frequency of postural drainage to every 2 hours he awake. The patient continues normal growth and development with his support systems intact. Billy Bragg. age 64. aged 5. Evaluation criteria for Mr. Although she was hospitalized several times in the last year for acute respiratory failure. Providing control and distraction c. intractable pain may not be relieved by treatment. b. The patient experiences decreased frequency of acute pain episodes. Pain is an objective sign of a more serious problem. Clifford's successful rehabilitation should include which of the following: a. She then let him watch TV and eat an apple Her intervention for pain are examples of: a. Altering Billy's environment d. Mr. His mother left him wash it and apply a smail amount of bacitracin and a Band-aid. b. Providing pharmacologic therapy b. Decrease activity to conserve functional Sung tissue. c. Smith would be to: a.Clifford's chronic pain and anxiety about his appearance did contribute to his losing his job and disrupting his plans for marriage. . received a small paper cut on his finger. The patient has no aftermath phase of his pain experience. d.
" d. b. the nurse should. Remove bronchia! secretions. 89. Situation 12: Mrs.d. Lippett.. Stay with the patient & periodically draw her attention of the food on the right side of the tray to prevent unilateral neglect 90. age 66. "There will be no complications. Teaching the patient relaxation techniques and breathing refraining exercises. c. "You may fee! a burning sensation when the dye is injected. and manage oxygen therapy. 87. b. improve and maintain pulmonary ventilation and gas exchange. a. Encouraging the family to take increased responsibility for the patients care. Place all the food on the right side of the tray.What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex? .in the care of patient with COPD who are in acute respiratory failure is to: a. c. Before leaving the room. d." c." 91. and her arterial blood studies now indicate she is again in acute respiratory failure. b. Place food and utensils within the patient's left visual field. d. The primary nursing intervention most commonly required . Plan with family for home care. Protecting the patient from knowing the prognosis of her disease. The nurse should include which of the following in preprocedure teaching for a patient scheduled for carotid angiography? a. Smith has been treated aggressively for acute respiratory failure and has improved over the past four weeks." b. She experienced anxiety about being prepared for discharge. Lippett. d. Discourage patient from sitting in Fowler's position in order to reduce work of heart. Mrs. remind the patient to look over all the tray. 88. Establish initial stage of activity. "You will be put to sleep before the needle Is inserted. Smith's condition has changed over a period of days. is experiencing sensory and perceptual problems that affect her right visual field (right homonymous hemianopia). Mrs. Discouraging the patient from performing activities of daily living if they make her tired. c. The nurse who cares for her should help her develop ways to cope with her chronic obstructive lung disease by: a. "The test will take several hours. When placing a meal tray in front of Mrs.
and a footboard. a. On the back with no pillows used. On the side with support to the back." 94. 95. brush your teeth?" b. c. with trochanter rolls and a footboard. "When would you like to have your bath?" d. b. b. c. 93. Use aseptic technique for the insertion site. b. hips slightly flexed. Use clean technique for cleansing connections and aseptic technique for the insertion site. c. c.a. Expressive aphasia and paralysis on the right side of the body. Expressive aphasia and paralysis on the left side of the body. Wait for the patient to complete the sentence. Mixed aphasia and paralysis on the right side of the body. Immediately begin showing the patient various objects In the environment. 92. On the back with two large pillows under the head. d. pillow under" the knees. Leave the room and come back later. b. hips slightly flexed. "I want a . and hands tightly holding a rolled washcloth. d. Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs? a. "Where is y our toothbrush?" c. . Close any leaks in the tubing with tape. Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke? a.. Begin naming various objects that the patient could be referring to. "Would you like to brush your teeth. Dysarthria and paralysis on the right side of the body." and then stops? a.To prevent infection in a patient with a subdura! intracranial pressure monitoring system in place. . Use sterile technique when cleansing the insertion site d. d. On the side with support to the back. the nurse should. or do you want me to do it for you? it's good to do things for yourself. "What would you like to do first. What would be the most appropriate intervention for a patient with aphasia who state. pillows to keep the body in alignment.. and a washcloth placed so that fingers are slightly curled. with pillows to keep the body in alignment.
Taylor understands the instructions by her identification of which of the following symptoms? a. Elevating the affected leg on two pillows or supports. The nurse would determine that Mrs. c. c. 99. The nurse would determine the maximum dosage and the need for dosage reduction by asking Mrs. Intermittently cross and uncross legs several times daily. Local and systemic infections b. d. Positive Homan's sign and Inability to bear weight. suffers from degenerative joint disease due to osteoarthritis and is admitted for a total joint replacement of the right hip. age 74. b. Martin. Tayior. Martin to report which of the following symptoms? a. Bleeding gums and bruising . the nurse should maintain correct position of Mrs. Before discharge. Taylor's operative leg by: a. the nurse reviews the signs and symptoms of joint dislocation with Mrs. Range of motion in the affected joint 97. Avoid weight bearing until the hip is completely heated. Positioning her supine and on the operative side. Tayior. Severe hip pain with shortening of the extremity. Maintain hip flexion at 90 degrees when sitting. Limit hip flexion to only 45 to 50 degrees. the physician orders antiuric acid medication to be given in large doses until the maximum safe dosage can be determined. During the preoperative period. a.Situation 13: Mrs. age 66. Following arthroplasty. Severe pain and swelling of the affected hip joint. d. the nurse should focus assessment primarily on: a. d. When discussing physical activities with Mrs. the nurse should instruct her to. sudden deformity of the affected hip joint. 96. As part of treatment of gouty arthritis for Mrs. b. c. 100. Taylor. Placing sandbags or pillows to Keep leg abducted. Placing an abductor wedge or pillows between the legs. Response to pain medications d. b. Painiess. 98. Self-care ability c.
Blurred vision and nausea . and diarrhea c. vomiting. Gastric irritation and heartburn d. Nausea.b.
of the following conditions may be developing? a.V. the client has a large amount of urine and a serum sodium level of 155 mEq/dl. I. Two days after the admission. Diabetes insipidus b. Diabetic insipidus c. After a thorough assessment and laboratory works shall shows serum ketones and serum glucose level above 300mg/dl. Subcutaneous b. Diabetes ketoacidosis c. bolus followed by continuous infusion 5. Hypoglycemia d. Hypernatremia and hypercaleemia 4. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated from diabetic ketoacidosis by which of the following conditions? a.V bolus only d. a. Which of the following method of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis. Intramuscular c. Hypokalemia and hypoglycemia b. Serum osmolarity c. Syndrome of inappropriate ant-diuretic Hormone secretion 2. Hyperglycemia b. Hypocalcemia and Hyperkalemia c.Situation 1 A client is brought into the emergency department with brain stem contusion 1. Somogyi phenomena 3. Myxedema coma b. Which. insulin to a client diagnosed with diabetic ketoacidosis? a. Type 1 diabetes mellitus d. what condition would be diagnosed to patient? a. I. Which of the following combinations of adverse effects must be carefully monitored when administering I.V. Hyperkalemia and hyperglycemia d. Absence of ketosis .
Place two tablets under the tongue when the intense pain occurs b. Coronary thrombosis 7. Arterial Spasm b. Layag'a anginal pain. Reynaldo Layag executive officer. When teaching how to use nitroglycerine. The nurse should realize that the angina pectoris is a sign of: a. Blocking of the coronary veins d. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs d. Layag to: a. Irritation of the nerve endings in the cardiac plexus 9. Swallow 1 tablet and place 1 tablet under the tongue when pain is intense c. Layag state that his anginal pain increases after activity. Fish b. Whole milk d.L. Mitral insufficiency b. Hypokalemia Situation 2: Mr. When cardiovascular disease is concern. Ischemia of the heart muscle c. the nurse should stress the importance of increasing the intake . is prescribed for Mr. Nitroglycerine S. The nurse realizes that the pain associated with coronary occlusion is caused primarily by: a. soft margarine 10. who has been placed on a high-unsaturated fatty acid diet. Mr. reduction of the saturated fat in the diet may be desired and substance made of polyunsaturated fat When teaching about this diet the nurse should instruct Mr. 6. Myocardial infraction c.d. Layag. the nurse tells him to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persist. was brought to the hospital because of chest pain-Diagnosis of angina was established. Place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent reoccurrence 8. Myocardial ischemia d. The nurse should tell Mr. Layag to avoid : a. Corn Oil c. When teaching Mr.
of: a. The stage of growth and development basically concerned with the role identification is the: a. if possible. Latency stage 13. 11. because of me effects on personality development during the . Rejects the parent of the same sex b. Play for the preschool-age child is necessary for the emotional development of: a. Resolution of the oedipal complex takes place when the child overcomes the castration complex and: a. Loves and hates ( ambivalence) both parents b. Oedipal Stage d. 12. Projection b. such as beef c. Genital-Stage c. Enriched whole milk b. Introjection c. Identities with me parent of the same sex d. Loves the parent of the same sex and the parent of the opposite sex c. Liver and other glandular organ meals Situation 3: A group of nursing students were discussing the normal growth and development concepts when assigned to observe the school children. Red meats. Competition d. Vegetables and Whole Grains d. Introjects behavior of both parents c. During the oedipal stage of growth and development. Loves the parent of the opposite sex and hates the parent of the same sex d. Independence 14. the child: a. Oral Stage b. Identifies with the parent of the opposite sex 15. Love the parent of the same sex and hates the parent of the opposite sex. Any surgery should be delayed.
The drainage has stopped 19. Recto that he can normally experience: a. When should the nurse increase. Which of the following measures should you encourage Mr. The drainage has stopped 18. Oral Stage. in order to regain urinary control? .Transurethral resection prostatectomy. The following are the possible complications after prostatectomy except: a. 60 years old.Recto? a. b. To maintain the patency of me bladder d. the nurse should inform Mr. After the removal of the three way catheter. To dilute urine 17. Urethral structure c. Recto. Recto to do. Erectile dysfunction d. (TURP) is performed to Mr. Dysuria d. Which of these statements explain the reason for continuous bladder irrigation? a. Anal Stage c. Residual urine b. Polyuria c. Post operatively he has continuous irrigation (Cystoclysis). To maintain the patency of the catheter c. Nursing assessment is vital to prevent and detect indications of postoperative complications. the flow rate of cystoclysis of Mr. Dribbling incontinence b. Latency Stage Situation 4 . The drainage appear cloudy b. The drainage is continuous but slow c. due to prostate enlargement. 16. The drainage is bright red d.a. The drainage has stopped 20. Oedipal Stage d. To remove clot from the bladder b.
Nurse Joan was assigned in the medical ward. Take warm bath 2 times daily c. interfering with the nerve transmission 25. When teaching the client.Nurses are generalist. Ambulate frequently d. Wear scrotal support b. During the endorsement she found out that she was assigned to several patients of different case 21. When developing a teaching session on glaucoma for the community. Glaucoma can be painless and visions may be lost before the person is aware of the problem. Which of the conditions is an early symptoms cgmmonly seen in Myasthenia Gravis? a. Destruction of the brain stem and basal ganglia in the brain b. Glaucoma is easily corrected with eye glasses b. Dysphagia b. depleting dopamine c. Bleeding into the brain stem. Respiratory Distress 23. Loss of myelin sheath surrounding peripheral nerves b. An autoimmune disorder that destroys acetlycholine receptors 24. Yearly screening for people ages 20 to 40 years is recommended d. Which of the following pathophysiological processes are involved in multiple sclerosis (MS)? a. which of the following statements would the nurse stress a. White and Asian individuals are the highest risk of glaucoma c. Degeneration of the substantia nigra. causing pressure on the spinal cord c. Which of the following statements best describes the Parkinson's Disease? a. 22. with Meniere's disease. resulting in meter dysfunction d. which of the following . Fatigue improving at the end of the day c. Ptosis d. Development of demyelinization of the myelin sheath. Degeneration of the nucleus pulposus. in order to cope up with the works demand you must have broad knowledge on anything. Alternately tense and relax the perineal muscles Situation 5 . Chronic inflammation of rhizomes just outside the central nervous system d.a.
Sputum d. Get up slowly. NPO for 12 hours prior to obtaining of specimen c. was admitted to the hospital with complaints of a burning sensation in the epigastric area after eating and inability to sleep at night. Gastric juice 28.instructions would a nurse give about vertigo. except: a. Diet that prevents gastric irritation in case of Mr. Fluid intake is increased d. A diagnosis of Peptic Ulcer was made.I. He was placed on bed rest and schedule for diagnostic studies. Meatless diet for 48 hours prior to obtaining of specimen 29. a. Gastroscopy b. X -ray examination for Mr. Punsalan for occult blood examination is : a. Punsalan to detect tumors or ulcerations of the stomach and duodenum is: a. a. An occult blood examination was ordered. Mr. turning the entire body d. Punsalan is. Punsalan is: .Mr. Change your position using the logroll technique Situatitm 6 . Drive in daylight hours only c. GIT series c. Punsalan is 36 years old. Fluid intake is limited only 1 liter/day b. 26. Sodium bicarbonate 27. Magnesium carbonate d. Blood c. The specific specimen needed from Mr. Aluminum hydroxide b. series d. Calcium bicarbonate c. Preparation of Mr. Stool b. Ba enema 30. Punsalan with gastric pain is advised to take any one of the following antacids. Cold G. Report dizziness at once b.
Eight Cranial Nerve (Vestibulocochlear) 34. Mr. Observe him for signs of Brain injury b. Decreased carotid pulses b. The nurse should . a. Bleeding from oral cavity c. Reyes. Liquid Diet c. Observe for symptoms of decreased intracranial pressure and temperature 35. Elevate the foot of the bed if he develops symptoms of shock d. Reyes has a possible skull fracture. Reyea complains of hearing ringing noises. Wait for him to verbally state needs regardless of how long it may take c. the nurse should assess for a. Confusion or delirium can be a defense against further stress b. Teaching based on information progressing from the simple to the complex d. Frontal lobe b. Provide positive feedback when he uses the word correctly b. Full Diet d. Reyes suffered head injuries in a motor vehicle accident 31. Six cranial nerve (abducent) d. Reyes cannot participate in verbal . Bland Diet b. The nurse recognizes that this assessment suggests injury of the a.Mr. When caring for Mr. Occipital lobe c. Mr. The nurse should: a. High Protein low fat diet Situation 7 . Mr. Absence of deep tendon-reflexes 32. interrupting mental activity c. since he is unaware of surroundings 33. Reyea has expressive aphasia. A minimum of information should be given.a. Suggest that he get help at home because the disability is permanent d. The nurse provide new information slowly and in small amounts because. Altered level of consciousness d. Reyes is extremely confused. As a part of a long range planning. a. Mr. Check for hemorrhaging from the oral cavity c. Destruction of brain cells has occurred. Help the family to accept the fact that Mr.
A reduced amount of neurotransmitter acetylcholine c. A genetic defect in the production of acetylcholine b. Males ages 15 to 3 5 years b. Involuntary twitching of small muscle groups 37. Clients with myastherda gravis.Barre Syndrome or amyothrophic sclerosis experience: a. A hypothermia blanket d. it is important for the nurse to check the bedside for the presence of: a. Because of the client's resistance to Neostigmine Situation 9 . Guillain . To provide safe care for Mrs. A tracheostomy set b. A decreased number of functioning acetyl-choline receptor sites d. Increased risk of respiratory complications c. To rule out cholinergic crisis c. Edrophonium HCL is ordered: a. For its synergestic effect b.Patricia Zeno is a client with history myasthenia gravis. Progressive deterioration until death b. To confirm the diagnosis of myasthenia d. Deficiencies of essential neurotransmitter d. is admitted . 36. An intravenous set-up c.treatment with neostigmine. Zeno asks the nurse why the disease has occurred. Zeno. The nurse bases the reply on the knowledge that there is: a. Myasthenia gravis most frequently affect: a. 39. Female ages 10 to 30 years old d. A syringe and edrophonium HCl(Tensilon) 40. a 38 year-old school teacher with rheumatoid arthritis. Zeno continues to become a weaker despite .Hariet. Mrs. An inhibition of the enzyme Ache leaving the end plates folded. Both sexes ages 20 to 40 years 38. Children ages 5 to 15 years c.communication Situation 8 . Mrs.
Salt free and low fiber b. Meperidine 30 mg q4 pm Situation 10 .5 mg. Relieve pain b. Complete immobility is desired during the acute phase of inflammation d. Aspirin. Reduce inflammation c.Lizbeth 20 year-old college student is brought to the hospital by her mother who states that for the past week her behavior has become very strange. a. exercises and physical therapy is ordered for Hariet This regimen will. the nurse should take into consideration the fact that: a. High calorie with low cholesterol c. She . Prevent ankylosis of the joint 43. Codeine . 30 mg.6 g_q4 c. TID b. Inflammation of the synovial membrane will rarely occur b. 41. The nurse explains that the most important reason for doing this is to: a. Halt me inflammatory process c. High protein with minimal calcium d. Xanax 0. a. When planning nursing care for Hariet. Hariet ask the nurse why the physician is going to inject hydrocortisone into her affected joint. Help prevent the drippling effects of the disease d. Prevent arthritic pain b. A regimen of rest. 0. Provide for the return of joint motion after prolonged loss 42. The diet the nurse would expect the physician to order for Hariet would be: a.to the hospital with severe and swelling of the joints of both hands. Bony ankylosis of the joint is irreversible and causes immobility c. The medication the nurse would expect to prescribed to relieve Hariet's pain. q4 d. Provide Psychotherapy d. they signify irreversible damage 44. Regular diet with vitamins and minerals 45. If the redness and swelling of a joint occur.
a. Waxy flexibility d. Fluid intake and output b. During the physical assessment Lizbeth's arms remains outstretched after her pulse and blood pressure were taken and the nurse has to reposition it for her. The patient is aware of what is going on around her and could respond if she wants to. does not eat or drink. ' 46. All of the following interventions would be appropriate except: a. Vital signs such as T.R. The patient is aware of what is happening around her even though she does not respond c. Restrain me patient and call for help b. a.P. She strips her clothing and strikes out widely at anyone she sees. Lizbeth suddenly begins running up and down the hall. Obtain me order and prepare chlorpromazine (thorazine) 50. the nurse first priority id to assess her: a. Lizbeth keeps her eyes closed and does not answer the questions asked by the nurse or physician. and blood pressure 49. Skin turgor c. Lizbeth is showing. Authoritarian and directive b. Muscle rigidity c. Call for the assistance of at least three staff members c.Diagnosis: Schizophrenia Catatosis. Bowel elimination d. The patient can cannot hear nor understand what is being asked b. While Lizbeth remains in an unreasonable state.has become more and more withdrawn . the therapeutic approach of the nurse is one that is: a. Related casual and friendly c. Permissive and comforting . Clear the area of other patients d. The patient is in regressed state and should be treated like a frightened child d. Distractability b. The nurse know that. One evening. When Lizbeth become agitated. Echopraxia 47. 48.
" I can take either a tub Bath or a shower when I feel it" . Temperature 55. Vaginal culture for Neisseria Gonorrhoeae d. Which of the following should the nurse do first? a. 36 weeks gestation visits the hospital because the suspects that her bag of water was ruptured. Frequent assessment of cervical dilation b.Michelle. she states that her bag of water ruptured few minutes ago. Perform a sterile vaginal examination 52. Turn the client to her right side c. which of me following would the nurse expect the physician to order? a. if the membrane has ruptured the paper which of the following color? a. Blue 53. After being confirmed that membranes has been ruptured and there was no evidence of labor. Check the status of the fetal heart rate b. Yellow b. While the nurse is assessing Michelle. Urinary Output d. the nurse noted that her cervix is 2 cm dilated and 50% effaced. the nurse uses nitrazine paper. Green c. Red blood cell count b. After instruction about care while at home. Sonogram for amniotic fluid volume index 54. Which of the following would the priority assessment for this client? a.d." b. Blue d. "It is permissible to douche if the fluid irritates my vaginal area. Test the leaking fluid with nitrazine paper d. Calm and firm but not threatening Situation 11. Michelle is to be discharged home on bed rest with follow -tip by the community health nurse. Degree of Discomfort c. Few hours after. Intravenous oxytocin adminitration c. 51. which of the following client's statements indicates effective teaching? a. To confirm Michelle's statement.
Jerome. Diagnosis: Bipolar I disorder. a. 57. " I should contact the doctor if my temperature is 100. Flight of Ideas b. During a nurse patient interaction. Playing basketball b. Initially one of the following activities would be appropriate for Jerome. This is known as: a. Gardening d. Ineffective individual coping b. Potential for violence. self directed d." Situation 12 . a. An expression of destructive impulse b. Neologism 59." d. Protect him against suicidal attempts d. was admitted to the hospital with periodic episode of manic behavior alternating with me depression. Provide adequate food and fluid intake 58. Jerome jumps rapidly from one topic to another. Prevent him from assaulting other patients c. Playing chess c. "I shouldn't limit my fluid intake to less than 1 quart daily. 56. Sensory perceptual disturbance 60. Altered family process c. A priority nursing diagnosis would be a. A means of coping with frustrations and disappointments c. should give priority to: a. A Means of Ignoring reality d.c. Writing . Idea of Reference c. a 37 years old man. An attempt toward off feeling of underlying depression. Nursing care plan for a hyperactive patient like Jerome. Discourage him from manipulating the staff b.4 F or higher. Clang association d. Which of the following statements is true and manic reaction? It is.
weight loss. and low-grade fever. Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)? a. Joints b.. Connective b. Heart c.. The nurse is aware that this is a disease of: a. " I need to stay away from sunlight" b. B. Anemia b. 61. "I don't have to worry about changing my diet. Vomiting b. . Rheumatic arthritis d. connective tissue d.Mr Gil age 86 years. Baldo . I need to work on managing stress in life. throat c. Mr Balao asks the nurse as to the source of this disease. Systematic lupus erymematosus (SLE) primarily attacks which of the following tissues? a. elbows. Which of the following symptoms is a classic sign of systemic lupus erythematosus (SLE)? a. Nerve 63." 64. "I don't have to worry if I get a strep. 36 years old patient complaints of fatigue. purine metabolism Situation 14 ." d. Weight loss c. He also has pa in his fingers. has been diagnosed with Alzheimer's disease.Mr. Which of the following conditions is suspected? a.Situation 13 . and ankles. Leukemia c. Lung d. Superficial lesions over the cheek and nose 65. Systematic Lupus Erythematosus (SLE) 62. Difficulty urinating d. Bones c.
Gil? a. Variable c. Remissions & exacerbations c. Non-stimulating 69. Gil? a. Attempt to give nursing care when he is in a pleasant mood 68. How can the nurse best care for Mr. a full term male child. Occupational therapy d. Remotivation therapy 70. Gilwhen he is angry and sad c. Slowly progressive deficits in intellect. At the time of delivery. Try to point out reality to him b. Gil frequently switches from being pleasant and happy to being hostile and sad without apparent external cause. Interaction with the environment c. baby Philip's blood is typed to determine the ABO . Avoid Mr. Challenging d. Rapid deterioration of mental functioning because of arteriosclerosis d. Which characteristics could the nurse expect when observing Mr.66. Encourage him to talk about his feelings d. Diminished psychologic faculties b. which may be noted for a long time 67. Gil when he is experiencing dementia and delirium? a. Which therapy might help him achieve this goal? a. Participation with the environment d. Familiar b. Face to face contact with the other clients Situation I5: Baby Philip. Gil? a. is delivered by his mother who is RH negative. Gil will need assistance in maintaining contact with society for as long as possible. Transient ischemic attacks b. 71. Psychodrama b. Recreation therapy c. What is the nurse's primary objective for Mr. What type of environment should be provided by the health care team for Mr. Mr. Mr.
and antibodies are formed in the fetus that destroy red blood cells. 74. so she produces anti-RH antibodies that cross the placental barrier and cause hemolysis of red blood cells in infants b. Tell her that all babies have them and they clear up in 2 to 3 days b. The nurse should: a. His RBC's will not be destroyed by the maternal anti-RH antibodies 73. If RhoGAm is given to Baby Philip's mother after delivering Baby Philip. When the nurse brings Philip to his mother. Baby Philip is RH positive and his mother is RH negative. Philip's mother has some titer in her blood 75. The RH factor is not genetically determined b. It is neutral and will not react with his blood c.group and the presence of the RH factor. Hyperbilirubinemia is anticipated to baby Philip because of RH incompatibility. The infant develops a congenital defect shortly after birth that causes the destruction of red blood cells. Philip's mother has no titer in her blood d. It is me same as die mother's blood b. Philip's mother is Rh positive b. Baby Philip is Rh negative c. The nurse is aware that: a. Baby Philip is to receive an exchange transfusion. The mother's blood does not contain the RH factor. The RH factor of the fetus is determined by the father d. Not all infants of RH-positive fathers are RH positive c. which was passed the fetus through the placenta. she comments about the milia on the baby's face. During gestation. It eliminates the possibility of a transfusion reaction occurring d. Explain that these are birthmarks that will disappear within a few months c. the condition that must be present rbr the globulin to be effective is that: a. The mother has the history of previous yellow jaundice caused by a blood transfusion. c. d. The nurse know that he will receive RHnegative blood because: a. the RH factor of the fetus may change 72. Hyperbilirubinemia occurs with incompatibility between mother and fetus because a. Instruct her about proper handwashing since the milia can be infectious . The mother's blood contains the RH factor and the infant's does not.
Hallucination b. Reviewing history of involuntary commitment d. Provide an anxiety-free environment c. Use logic and be persistent b. The nurse hears him saying. "If come any closer. An appropriate activity for the nurse is to recommend for a client who is extremely agitated is: a." c. "That's a silly thing to say. The nurse's continued assessment should include: a. Delusion c. Observing Ronald for rising anxiety c. "Tell me more about this. Encourage ventilation of anger 79. The best response for the nurse to make to this behavior is: a. Checking dosage of prescribed medication 80." d. "I'm the nurse. 76. When communicating with the paranoid client. As the nurse approaches Ronald he says. "Those doctors are faying to commit me to the state hospital. "How can I hurt you?" b. Idea of reference 77. Illusion d. Instruct her to avoid squeezing them or attempting to wash them off Situation 16: Ronald 23 years old was voluntarily admitted to the in-patient unit with a diagnosis of paranoid schizophrenia. I'll die. Bingo c. Competitive sports b. Express doubt and do not argue d. Ronald is pacing the hall and is agitated. Daily walks . the main principle is to: a. Trivial Pursuit d." 78.d." This is an example of: a. Clarifying information with the doctor b.
Hemorrhage and infection b. Dehydration and hemorrhage c. An adherent painful ovarian mass b. Subiiivolution and dehydration d. the nurse should first a. Lately he has been developing a plan of action. age 67. Sharp lower right or left abdominal pain radiating to the shoulder 82. Sudden knife-like. Check the fundus for firmness b. Give her the sedation c. Lim has been complaining of vaginal bleeding and one sided lower quadrant pain. Arnold is admitted to . Lim has had confirmation of her pregnancy. has had successfully treated depressive disease for more than 10 years. Abruptio placenta b. The nurse would suspect an ectopic pregnancy if Mrs Lim complained of: a. Intermittent abdominal contractions c. diagnosed. The most common type of ectopic pregnancy is tubal. She presents the emergency room with abdominal pain not yet. Within a few weeks after conception the tube may rupture suddenly. Painless vaginal bleeding b. An incomplete abortion c. upper-quadrant abdominal pain d. 81. causing: a. Continues dull. take her immediately to the delivery home 85. Leukonhea and dysuria a few days after the first missed period d. Immediately notify the physician d.Situation 17: Mrs. After a spontaneous abortion the nurse should observe the client for: a. Mrs. An ectopic pregnancy d. To give safe nursing care. A few hours after being admitted with a diagnosis of inevitable abortion. lower-quadrant abdominal pain 83. Lower abdommal cramping for a long period of time c. The nurse suspects mat she has: a. a client begins to experience bearing down sensations and suddenly expels the products of conception in bed. A rupture of graafian follicle 84. Signs of pregnancy-induced hypertension Situation 18: Arnold.
There will be a memory loss aa a result of the treatment c. Which assessment would best aid the nurse in evaluating Arnold's potential for suicide? a. Shows fearful of his own impulses and is seeking protection from them 89. . Wishes to frighten the nurse b. Arnold confides to the nurse that he has been thinking of suicide. He is being readmitted for a palate repair. 86. development plans for discharge from hospital or program 88. Ask him if suicide was ever or is now being considered 87. Ask him about plans for the future b. Which would be the most therapeutic way to provide his safety measures? a. Ask the family if he had ever attempted suicide d. Length of time the depression has existed c. Sleep will be induced and treatment will not cause pain b. Ask other clients about suicide while in a group c. Not allow him to leave his room b. Give him the opportunity to ventilate feelings d. Which of the following motivations should the nurse recognize in Arnold? a. Remove all sharp and cutting objects c. Presence of multiple personal problems b. should tell him which of the following information? a. Feels safe and can share his feelings with the nurse d. Impending of the loss of a loved one c. The nurse when discussing ECT with Arnold. Wants attention from the staff c.hospital for reassessment. Arnold is placed on suicide precautions. but he can asks any question Situation 19: Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. Assign staff member to be with him at all times 90. It is better not to talk about it. The psychiatrist prescribes Electro convulsive therapy for Arnold. Which factor is most important in evaluating Arnold's risk for suicide? a.
and electric trains b. Marble tracks and small blocks encouraging fine-motor coordination d. large altered nipple c. Limited to IV fluids b. The toothbrush might be frightening to Josh d. Which of the following nursing actions would have been included for Josh following his cleft lip repair? a. Colorful mobiles. Facilitated by the use of spoon or medicine dropper 94. who is caught in me raging conflict between his mother and his wife. and marble tracks 92. Josh would probably have no teeth c. The nurse understands which of the following concepts about Vincent's . music boxes. Wish a soft.91. Accomplished per gastrostomy tube d. Josh's previous hospitalization c. The suture line might be injured b. feeding will probably be: a. he is referred for a psychiatric consultation and is found to have a conversion disorder. Toys requiring pushing. complains of pains in his right leg that has progressed to the point of paralysis. 96. Cleansing the suture line to prevent infection c. When a toddler is hospitalized. Josh would not be accustomed to a brush at home Situation 20: Vincent. Using a spoon to administer oral feedings b. age appropriate toys would include: a. Never leaving Josh with strangers d. Why will Josh be unable to use toothbrush postoperatively? a. Prior to a repair of a unilateral cleft lip and palate. Assurance of affection and security 93. After orthopedic consultation has shown no pathology. Gratification of Josh wishes b. Positioning Josh on the abdomen to avoid aspiration 95. pulling and to big to be swallowed c. wind-up toys. Which of the following would be the most important factor in preparing Josh for his hospitalization? a. Allowing Josh to suck on a pacifier to prevent crying d. age 26. Wind-up toys.
Demonstrate a spread of paralysis to other body parts b. It is reversible and will subside if he is helped to focus on other things d. Exhibit free floating anxiety c. Require continuous psychiatric treatment to maintain individual functioning c. Hostile feelings towards his home b. Avoid focusing on his physical symptoms d. Vincent's conflict may be caused by which of the following stimuli? a. Which intervention would be most therapeutic for the nurse to make? a. It is usually necessary for him to cope with the present situation c. Inadequate feelings in regard to assuming the role of husband 98. How would the nurse expect Vincent to behave? a. depending on exposure to stress 99. Demonstrate anxiety when discussing symptoms 100. again develop similar symptoms d. Tell him there is nothing wrong c. Encourage him to try to walk b. Appear gently depressed b.conversion disorder? a. Appear calm and composed d. Help him follow through with the physical therapy plan . It will probably be solved when he learns to deal with ongoing family conflicts 97. Needs to be a dependent child and an independent adult d. Recover the use of the affected leg but under stress. Follow a rather unpredictable emotional course I the future. Which behavior is Vincent most likely to manifest? a. Ambivalent feelings toward his wife c. It is an unconscious method for him to cope with the present situation b.
A nurse should teach a patient who is taking chlorpromazine (Thorazine) to avoid: a. Given the Diagnosis and Statistical Manual of Mental .1. "Tomato soup!" Which of the following actions by the nurse would be correct? a. Ordering an EEG 2. A client is admitted with Wernicke's encephaiopathy." d." c. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. A patient who has AIzheimer's disease is told by the nurse to brush his teeth. would be age-appropriate? a. Doing the procedure for him 4." b. which of the following interventions is considered critical? a. The nurse anticipates that the first physician's order will include: a. "I know i will never see my mother again. "I can't wait to go get pizza with my brother. d. Clarifying the meaning of his statement c. Setting fewer limits in order to allow for more expressions of feeling b. Exposure to the sun b. "I'm glad my mother isn't crying anymore. Two weeks ago. Drinking fluids high in sodium d. Which of the following statements. 6. Focusing on the emotional reaction b. He shouts angrily. Providing more frequent opportunities for interaction with others." 3. if made by a four year old child whose brother just died of cancer. his girlfriend broke off their engagement and cancelled the wedding. such as Decadron c. in caring for a psychotic patient who is experiencing hallucinations. "i know where my brother is buried. Constantly negating the patient's hallucinatory Ideations. c. Administering a steroid medication. Ordering an MRI b. Giving thiamine 100 mg IM STAT d. Eating foods such as chocolate and aged cheese 5. Maintaining constant observation. Giving him step-by-step directions d. Swimming in a chlorinated pool c.
The nurse finding that which of the following values is elevated? a. Paranoid d. Exploitative c. Current treatment for pneumonia b. Antisocial b. Her future children will be at risk for developing schizophrenia b. Hypersensitive d. text' revised (DSM-IV-TR) criteria for this disorder the nurse expects to find which of the following data during the interview with the client? a. A client tells the nurse that her co-workers are sabotaging the computer. Histrionic c. One of her parents may develop schizophrenia later in life d. Her twin has no diagnoses but has been experiencing significant anxiety since becoming engaged. Schizotypal 9. Evidence of delusions and hallucinations d. Regular use of alcohol and marijuana c. Seductive 10.Disorders. Hemoglobin F b. In counseling the engaged twin. She may have a predisposition for schizophrenia c. When the nurse asks questions. Eccentric b. It is unlikely that she wil! develop schizophrenia. A history of chronic depression 7. Hemoglobin S . edition. A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. at her age 8. it would be crucial to include which of the following tacts? a. A set of monozygotic twins who are 23 years old have begun attending groups at mental health center. Which of the following types of behavior is expected from a client diagnosed with paranoid personality disorder? a. One twin is diagnosed with schizophrenia. the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorders? a.
A nurse is assessing a client to determine the distress experienced after binge eating. Hypophosphatemia 13. A parent with a daughter with bulimia nervosa asks a nurse." 12. Bradycardia c. Which of the foilowing complications should be included? a. "A person with bulimia nervosa can maintain a normal weight. It's hard to face this type of problem in a person you love. Pain d. Hypokalemia d. Hypocalcemia b. "At first there is no weight loss." b. Loss of taste b. Hemoglobin a 11. Dental problems d. Ageusia b. Electrolyte Imbalance d. Amenorrhea b. Malabsorption of nutrients 15. Hemoglobin C d. Sore throat ." d. A nurse is talking to a client with bulimia nervosa about the complications of Laxative abuse. Which of the following symptoms are typical after bingeing? a. Swollen glands c." c. "This is a serious problem even though there is no weight loss. Yellow skin 14. Which of the following findings is expected based on laboratory test results? a. Headache c. Hypoglycemia c.c. "How can my child have an eating disorder when she isn't underweight?" Which of the following responses is best? a. Which of the following complications of bulimia nervosa Is life threatening? a. A nurse is assessing an adolescent girl recently diagnosed with an eating disorder and symptoms of bulimia nervosa. it comes later In the disease.
Talk about how she's different from her peers. She is alert.K. Chronic anxiety d. patients require extensive teaching regarding this major alteration in their lifestyle a. 18. as well as the feeling of weakness that began this morning. b. Encourage her to look at herself in a mirror. 19. Teach the family principles of assertive behavior. She calls the nurse to her room to express her concern about the frequency of urination she is experiencing. c. A decrease in postoperative stress causing poiyuria b. Talk about how important the client is. Mental Illness b. Which of the following difficulties are frequently found in families with a member who has bulimia nervosa? a. Ms. Discuss the difficulties the family has in social situations." Which of the following Interventions is the best to use with this family? a. A client with anorexia nervosa tells a nurse. A client with anorexia nervosa tells a nurse she always feels fat. b. d. An expected result of the removal of the pituitary gland d. Substance abuse 17. d. Multiple losses c. an unusual complication c. Abnormal distribution of body hair . Explore the family's ability to express affection appropriately. oriented. Help the family convey a positive attitude toward the client. Address the dynamics of the disorder. is a 24-year old woman admitted to the neurosurgery floor 2 days following a hypophysectomy for a pituitary tumor. c. The most likely cause of her chief complaint this morning is a. J. Which of the following interventions is the best for this client? a.16. She is alert. "My parents never hug me or say I've done anything right. A frequent complication of the hypophysectomy 20. oriented and eager to return to her job as an executive assistant to the hospital director. Following hypophysectomy. and eager to return to her job as an executive to the hospital director. The onset of diabetes mellitus.
diaphoresis. Skin care q2h. fatigue. The need to undergo repeat surgical procedures 21. chest pain and oliguria 23. use pressure relief devices Ms. for the following signs and symptoms: a. respirations 12. fractured pelvis. motor response c. motor responses b. He had a mild contusion. bradycardia. verbal response. tachypnea. and severe leg pain d. petechiae b. Pupil size. motor response J. myocardial contusion. Results were not avaiIable upon transfer to the unit. respiratory therapy for intermittent positive pressure breathing therapy c. Loss of consciousness. petechiae. The nurse will monitor J.b. nausea and vomiting c. Skin care and position q2h. His vital signs BP 120/80. and fractured right femur. pupil size. She is a diabetic who been managed at 30 U NPH insulin every AM and a 1200-calorie ADA diet. respiratory exercises. a 34-year old white female. verbal response.E. and intermittent positive pressure breathing q2h d. maintain alignment of extremities. and nausea. J. 22. Appropriate nursing interventions for J. passive leg exercises daily. anorexia. muscle cramping. The three assessment factors included in this scale are: a. pulse 84. tachycardia. is admitted via the emergency room complaining of abdominal pain. is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen. Her glucose in ER 700 mg/dL. respiratory exercises. Regular insulin 30 U was given and a repeat glucose were drawn. motor response d. Change in the levei of consciousness. which nursing activities should be highest . bradycardia.E. response to pain.E. and temperature 99 F orally. would be a. Onset of chest pain. teach use of overhead trapeze. Change in leve! of consciousness. Skin care and position q2h and prn. Given the above Information. Eye opening. Skin care/bathe daily. but is alert and oriented. Lifetime dependency on hormone replacement c. Eye opening. The Glasgow coma scale is used to . The need to drink many fluids to replace those lost d. tachycardia..evaluate the level of consciousness in the neurological and neurological patients. 24. respiratory exercises b. teach use of overhead trapeze. response to pain.
Her diabetes is out of control c. indicates that the client has fulfilled minimal criteria for discharge from the PACU? a. Obtaining blood glucose results c. J is scheduled for surgery in the morning. Her glucose is now-100. Infection has increased her insulin needs 26. One point In each of the five areas . To prevent a hypoglycemic reaction c. The nurse received the lab results from the biood sample drawn in ER. However. Assessing neurological status d. . Immobilize the head and neck 28. the nurse would do which of the following? a. Provide a cane for support d. To provide calories to offset the patient being NPO b. Assessing pedai pulses and feet 25. Maintain proper body alignment b. Later that evening. Ms. To assist with the body's response to stress 27. When ambulating a client following surgical removal of a protruded intervertebral lurnbar disc. Which of the following point scores on the post anesthesia chart. The physician has written the following orders: -NPO after midnight -At 6 AM start-ari iV of D5W to be'infused at 250 ml/hr -15 U NPH insulin at 6AM -Draw FBS prior to initiating iV fluids The statement that best describe the rationale for these orders Is: a.priority? a. Administer anaigesia after walking c. A diagnosis of appendicitis is made and Ms. J's abdominal pain increased in intensity. What conclusion can the nurse draw basing on this information? a. To prevent a fluid volume deficit d. insulin administration increase WBC count d.for a total score of 5. Lab results are within normal limits. Monitoring vita i signs b.000 mm3. her WBC count is 25. no action Is necessary b.
Creation of a tracheostomy d. "TIA means a transient ischemic attack. The nurse would prepare for which of the following emergency Interventions? a. Wash the radiation site vigorously with soap and water to remove dead cells. The nurse should instruct the client to do which of the following? a. "It Is a temporary interruption in the blood flow to the brain. b. Drink warm fluids throughout the day to relieve discomfort in swallowing. 31. "I think you should ask the doctor. Following a thyroidectomy. Use the spray more frequently d. intravenous administration of calcium b. a client complains of dysphagia and skin texture changes." d. "When will this hotel bring me some food?" After confirming that the client is confused.above. the client asks the nurse. Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)? a. A client using an over-the counter nasal decongestant spray reports unrelieved and worsening nasal congestion. d." 30. b. the client experiences.hemorrhage. Two points each in each of the five areas for a total score of 10. and promote healing? a. 32.b. While receiving radiation therapy for the treatment of breast cancer." c. Would you like me to cail him for you?" b. A total score for the five areas of 7 or. insertion of an oral airway c. Combine the spray with an oral decongestant. Discontinue the medication for a few weeks c. Apply coo! compresses to the radiation site to reduce edema. c. Switch to a stronger dosage of the medication. 29. which of the . Eat a diet high in protein and calories to optimize tissue repair. circulatory. One point in at least three areas" respiratory. and consciousness . at the radiation site.for a total of 3 c. " The blood supply to the brain has decreased causing permanent brain damage. giving informed consent for surgery and the physician !eaves the room. After a client signs the form. Intravenous administration of thyroid hormone 33. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications. d.
but if you want the medication given.exercises. "I will not give this medication. Administering preoperative medication immediately . Teaching preoperative moving. as ordered . and deep-breathing. An Intrauterine device will be used to decrease vaginal bleeding c. Apply pressure by pinching the anterior portion of the for five to ten minutes b. d. Inserting a bladder catheter to urine output. Oral contraceptives will not be prescribed because they will increase the risk' of cancer 35. An ultrasound confirmed a hydatidiform molar pregnancy. The staff nurse calls a physician regarding an order to administer digoxin (Lanoxin) to a patient with a pulse of 55 and a serum potassium levei of 2. Apply ice compresses to the patient's forehead and back of the neck 36. coughing. Place the patient in a sitting position with the neck hyperextended c. "I'll give the medication but you wiil still be responsbIe if anything happens to the patient. "I'm sorry. Pregnancy will be restricted for another year d. Which of the following nursing actions is most appropriate to control the bleeding? a. the charge nurse learns that an elderly patient has become very confused and is shouting obscenities and undressing himseif." 37." b. shift report.The staff nurse's best response would be a. Which of the following actions should the nurse tell the patient to expect during her one-year follow-up? a. Which of the following actions is the most appropriate Initial nursing response? a. Pack the nostrils with gauze and keep the gauze in piace for four to five days d. Restrain the patient with a Posey jacket . the patient experiences epistaxis (nosebleed). b." d. Thirty minutes after the nurse removes a nasogastric tube that has been In piace for seven days.following would be the nurse's priority action? a." c. 34. c. '"I think we should discuss this with the nursing supervisor. At 16 weeks gestation. During the night. Multiple serum chorionic gonadotropin levels will be drawn b. Reporting that the consent has been obtained from a confused client. you will have to give it yourself.9 mEq/L The physician says to give the medication. no fetal heart rate was detected during assessment of a pregnant patient.
"Have you experienced a pounding headache?" d.000/ cu mm 39. When a woman is 10weeks pregnant which of the following hematology test results would need further Investigation? a. Complete a nursing assessment of the patient 38. The liquid antibiotic comes in a concentration of 125 mg/5ml. platelet count of 200.200. how many ml would the nurse administer with each dose? a. Medicate the patient with haloperidol (Haldol) as ordered. "When did you eat your last meal?" c. 2 . Using a low-pitched voice b.000/cu mm d. Enunciating each word . If the antibiotic were to be given three times each day. "Did you feel fluttering in your chest" 42.slowly c. A patient who is receiving total parenteral nutrition has an elevated blood glucose eve! and is to be administered intravenous insulin. An infant who weighs 11 lbs. Regular insulin (Humulin R) c. Hemoglobin level of 9 mg/dL b. Insulin zinc suspension (Lente) d.000/cu mm c. Notify the physician d. is to receive 750 mg of an antibiotic in a 24hour period. Reinforcing the words with pictures . Which of the foitowing techniques would a nurse use when interviewing a 94-year-old patient? a. "At what time did the pain start?" b. Isophane insulin (NPH) b. Which of the following questions would be most important for the nurse to ask? a. c. white blood cell count of 15. Which of the following types of insulin should a nurse has available? a. Varying voice intonations d. Semi-Lente Insulin (Semiterd) 41. A nurse is taking history from a patient who has just been admitted to the hospital withl an acute myocardia! infarction. red blood cell count of 4. 40.b.
the nurse should advise him to: a. When you report on duty. When discussing his smoking habits with Mr. The patient Is fasting 12 hours prior to test b. Mr. Smoke only right after meals d. Chew gum Instead 45. Fatigue d. Dyspnea only on exertion 47. You should know which of the following Is not. Anthony Malailinelii is a 54-year old truck driver. You would not find which of the following assessments in a patient with severe anemia? a.b. 6. Pallor b. Smoke low-tar. Smoke cigars instead c.correct concerning this test a. He is a heavy smoker.25 d. filter cigarettes b. 10 43. Vistaril) b. Cold sensitivity c. Various position changes are necessary during the test 46. Martinelii for gastric analysis. Acetaminophen (Tyienol) c. Spasm of the neck muscles developed in a patient who is taking phenothiazine (Nemazine). Which of the following medications should the nurse administer? a. Acetylsalicylic acid (Aspirin) d. Martinelli had an Hgb of 9. As the nurse preparing Ivlr. Smoking for 8 hours prior to test is not allowed d. Gastric contents are aspirated via a tube c. He is admitted for possible gastric ulcer. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload.8. Which of the following signs would not be likely to occur? . Martinelli. your team leader tells you that Mr. 44. Benztropine mesyiate (Cogentin) Mr. 5 c.
From these symptoms and his history. Distended neck veins d. b. Birth defects b. He has been on long-term phenothiazines (Thorazine). c. I'll come back and talk with you later." c. Remain calm and don't emotionally respond to the client's manipulative actions. Substance abuse 51. A client with antisocial personality disorder is trying to manipulate the healthcare team. Distracted easily c.' d. drooling and exhibits generaj dystonic symptoms." 49. moist gurgling respirations b. Help the client eliminate the intense desire to have everything in life turn out .. A client with antisocial personality disorder tells a nurse "Life has been full of problems since childhood. Parkinsonism c. the nurse concludes that the client has developed: a. Hypoactive behavior d. "I am a.a. Dystonia d. "I don't belong here. Help the client verbalize underlying feelings of hopelessness and learn coping skills. A 50 year-old male client has a history of many hospitalizations for schizophrenic disorder. Focus on how to teach the client more effective behaviors for meeting basic needs. Weak. and I'm on a tour. d. new staff member. "I can't do anything about that. Which of the following strategies is important for the staff to use? a. The nurse assessing this client observes that he demonstrates a shuffling gait. "What would you do if you were out of the hospital?" b. A new staff nurse is on an orientation tour with the head nurse. Tardive dyskinesia b. Please try to get me out. "I think you should talk to the head nurse about that. Akathisia 50." The staff nurse's best response would be: a. slow pulse c." Which of the following situations or conditions would the nurse explore in the assessment? a. A client approaches her and says. 400 mg/day. Dyspnea and coughing 48.
Amenorrhea Dyspareunia menororrhagia metrorrhagia 56. he will understand. The nurse plans to administer the medication In which of the following locations? a. Advise the woman to seek a gynecologic consult c. A client with antisocial personality disorder is beginning to practice several socially acceptable behaviors in the group setting. Which of the following conditions is best defined by this menstrual pattern? a. Which of the following outcomes will result from this change? a.A client with chronic obstructive pulmonary disease (COPD) tells the nurse. 52. In the gluteal muscle using Z-track technique . b. After a spinal cord injury. Tell the client. Acceptance of reality c. d. Suggest methods and measures that facilitate sexual activity. physician that an order has been written to administer an iron injection to an adult client. d. Fewer panic attacks b.perfectly. c. "if you talk this over with your husband. decreased physical symptoms 53. After a spinal cord injury. b. d. d. you may consider contraception if you don't want to become pregnant. women usually remain fertile. Refer the couple to a sex therapist. Sexual intercourse shouldn't be different for you. Which of the following discharge instructions would be most accurate to provide to a female client who has suffered a spinal cord injury at the C4 level? a. Improved self-esteem d. 55. After a spinal cord injury. A cllent tells the nurse she is having her menstrual period every 2 weeks and it lasts for 1 week. 54." Which of the following nursing interventions would be most appropriate? a. "I no longer have enough energy to make love to my husband. b. menstruation usually stops. therefore. women usually are unable to conceive a child. A nurse has just been toSd by a.
Which of the following events signifies when gender is first ascribed? a.b.56. in the anterior lateral thigh using a 5/8 inch needle ' 57. blood is sent to the laboratory for analysis.a+ 1. b. In the deltoid muscle using an air lock c. plan? a. C0221. A 59-year-old patient with a diagnosis of delirium is admitted to the hospital. Self-care deficit: feeding 58. A child receives sex-specific toys d. Fluid volume deficit c.0. glucose 100. Alteration in patterns of urinary elimination. To evaluate the cause of a patient's delirium. A child receives sex-specific clothing . In the subcutaneous fesue of the abdomen d. Cr 100. The results are as follows: M. A child attends school c. Nutritional deficit: less than body requirements d. K4' 4. Based on these laboratory result. BUN 86. the nurse should record which of the following nursing diagnoses on the patient's care. The nurse knows that gender Is part of one's identity. A baby is born b.