Professional Documents
Culture Documents
A. “My child might need an extra capsule if the meal is high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot chocolate
3. The mother brought her child to the clinic for follow-up check up. The mother tells the nurse that 14
days after starting an oral iron supplement, her child’s stools are black. Which of the following is the best
nursing response to the mother?
A. “I will notify the physician, who will probably decrease the dosage slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother asks the nurse if the
treatment given to her son is effective. What would be the appropriate response of the nurse?
A. I will review first the child’s height on a growth chart to know if the treatment is working
B. I will review first the child’s weight on a growth chart to know if the treatment is working
C. I will review first the number of prescriptions refills the child has required over the last 6 months
to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician during the last 6 months
to give you an accurate answer
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware that in taking this
medication, it is very important to:
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates for the migratory
polyarthritis accompanying the diagnosis of rheumatic fever. Which of the following activities performed
by the child would give a best sign that the medication is effective?
A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
13. The nurse is providing health teaching about the breastfeeding and family planning to the client who
gave birth to a healthy baby girl. Which of the following statement would alert the nurse that the client
needs further teaching?
A. “I understand that the hormones for breastfeeding may affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed less after birth”
C. “I may not have periods while I am breastfeeding, so I don’t need family planning”
D. “I can get pregnant as early as one month after my baby was born”
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The nurse assigned to
the client enters the client’s room and finds out that the client is using a soiled blanket brought in from
home. The nurse attempts to remove the blanket and replace it with a new and clean blanket. The toddler
refuses to give the soiled blanket. The nurse realizes that the best explanation for the toddler’s behavior
is:
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task of the child. In caring a 3-year-old-client, the
nurse knows that the suited developmental task of this child is to:
A. The older daughter be given more responsibility and assure her “that she is a big girl now, and
doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital, because she may harm her
new sibling
C. The older daughter stay with her grandmother for a few days until the parents and new baby are
settled at home
D. The mother spend time alone with her older daughter when the baby is sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom.
Which of the following is an appropriate toy would the nurse select for the child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for developmental problem?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to do preoperative
teaching with the child. The nurse should knows that the 5-year-old would:
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff development meeting
D. Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and with
one hand. “It is making me crazy!” What would be the best explanation of the nurse to the behavior of the
boy?
A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose more than 20 pounds”
28. The client visits the clinic for prenatal check-up. While waiting for the physician, the nurse decided to
conduct health teaching to the client. The nurse informed the client that primigravida mother should go to
the hospital when which patter is evident?
A. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
29. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and
breastfeeding, the nurse includes in her health teaching about the resumption of fertility, contraception
and sexual activity. Which of the following statement indicates that the mother has understood the
teaching?
A. “Because breastfeeding speeds the healing process after birth, I can have sex right away and not
worry about infection”
B. “Because I am breastfeeding and my hormones are decreased, I may need to use a vaginal
lubricant when I have sex”
C. “After birth, you have to have a period before you can get pregnant again’
D. “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t need
any contraception until I stop breastfeeding”
30. A community nurse enters the home of the client for follow-up visit. Which of the following is the most
appropriate area to place the nursing bag of the nurse when conducting a home visit?
A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa
31. The nurse in the health center is making an assessment to the infant client. The nurse notes some
rashes and small fluid-filled bumps in the skin. The nurse suspects that the infant has eczema. Which of
the following is the most important nursing goal:
A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level
32. The nurse in the health center is providing immunization to the children. The nurse is carefully
assessing the condition of the children before giving the vaccines. Which of the following would the nurse
note to withhold the infant’s scheduled immunizations?
A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose
33. A mother brought her child in the health center for hepatitis B vaccination in a series. The mother
informs the nurse that the child missed an appointment last month to have the third hepatitis B
vaccination. Which of the following statements is the appropriate nursing response to the mother?
A. Wrapping used dressing in a plastic bag before placing them in the nursing bag
B. Washing hands before removing equipment from the nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a labeled container inside the nursing bag
36. The nurse is planning to conduct a home visit in a small community. Which of the following is the
most important factor when planning the best time for a home care visit?
A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the parent of a 6-month-old infant asks the health
nurse, “Why is our baby going to receive so many immunizations over a long time period?” The best
nursing response would be:
A. “The number of immunizations your baby will receive shows how many pediatric communicable
and infectious diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is determined by your baby’s health history
and age”
D. “It is easier on your baby to receive several immunizations rather than one at a time”
39. The community health nurse is conducting a health teaching about nutrition to a group of pregnant
women who are anemic and are lactose intolerant. Which of the following foods should the nurse
especially encourage during the third trimester?
A. Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins and iron
supplements
B. Prenatal iron and calcium supplements plus a regular adult diet
C. Red beans, green leafy vegetables, and fish for iron and calcium needs plus prenatal vitamins and
iron supplements
D. Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and iron supplements
40. A woman with active tuberculosis (TB) and has visited the health center for regular therapy for five
months wants to become pregnant. The nurse knows that further information is necessary when the
woman states:
A. “Spontaneous abortion may occur in one out of five women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with my baby until contagious is no longer a
problem
D. “I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33 million people suffer from food poisoning every
year. Salmonella enteritis is responsible for almost 4 million cases of food poisoning. One of the major
goals is to promote proper food preparation. The community health nurse is tasks to conduct health
teaching about the prevention of food poisoning to a group of mother everyday. The nurse can help
identify signs and symptoms of specific organisms to help patients get appropriate treatment. Typical
symptoms of salmonella include:
A. “Condoms should be used because they can prevent infection and because they may prevent
pregnancy”
B. “Condoms should be used even if you have recently tested negative for HIV”
C. “Condoms should be used every time you have sex because condoms prevent all forms of
sexually transmitted diseases”
D. “Condoms should be used every time you have sex even if you are taking the pill because
condoms can prevent the spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding program to all newly mothers. The nurse is
formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a breast-
feeding mother takes into account that breast-feeding is contraindicated when the woman:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
45. The City health department conducted a medical mission in Barangay Marulas. Majority of the
children in the Barangay Marulas were diagnosed with pinworms. The community health nurse should
anticipate that the children’s chief complaint would be:
A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain
46. The mother brought her daughter to the health center. The child has head lice. The nurse anticipates
that the nursing diagnosis most closely correlated with this is:
A. “I do not need to be concerned about the spreading of this infection to others in my family”
B. “I should apply warm compresses before instilling antibiotic drops if purulent discharge is
present in my daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at nighttime if I have eye discomfort”
D. “I should perform a saline eye irrigation before instilling, the antibiotic drops into my daughter’s
eye if purulent discharge is present”
50. A community health nurse is caring for a group of flood victims in Marikina area. In planning for the
potential needs of this group, which is the most immediate concern?
1. C. Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until
the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the
client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth
of a toddler who just undergone cleft palate repair. The general principle of care is that nothing
should enter the mouth until the suture line has completely healed.
2. D. The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not
a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s
integrity.
3. B. When oral iron preparations are given correctly, the stools normally turn dark green or black.
Parents of children receiving this medication should be advised that this side effect indicates the
medication is being absorbed and is working well.
4. C. Reviewing the number of prescription refills the child has required over the last 6 months
would be the best indicator of how well controlled and thus how effective the child’s asthma
treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would
require that the child take additional medication. This would be reflected in the number of
prescription refills.
5. D. Tetracycline may cause a phototoxic reaction.
6. D. The normal heart rate of an infant is 120-160 beats per minute.
7. C. Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal
failure; thus baseline renal function must be evaluated before initiating either medication.
8. C. In selecting the correct needle to administer an IM injection to a preschooler, the nurse should
always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous
fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle
gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that
is 1 inch long would be most appropriate.
9. C. The purpose of the salicylate therapy is to relieve the pain associated with the migratory
polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the
child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.
10. D. The recommended position to administer rectal medications to children is side-lying with the
upper leg flexed. This position allows the nurse to safely and effectively administer the medication
while promoting comfort for the child.
11. C. For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the
digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).
12. B. Chest physiotherapy treatments are scheduled between meals to prevent aspiration of
stomach contents, because the child is placed in a variety of positions during the treatment process.
13. C. It is common misconception that breastfeeding may prevent pregnancy.
14. B. The “security blanket” is an important transitional object for the toddler. It provides a feeling of
comfort and safety when the maternal figure is not present or when in a new situation for which the
toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security
blanket for the toddler.
15. D. Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In
order to accomplish this, the toddler must be able to explore and manipulate the environment.
16. D. The introduction of a baby into a family with one or more children challenges parent to
promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby
can set the stage for the other children’s reaction. Spending time with the older siblings alone will
also reassure them of their place in the family, even though the older children will have to eventually
assume new positions within the family hierarchy.
17. D. The autonomous toddler would be frustrated by being confined to be. The pounding board and
hammer is developmentally appropriate and an excellent way for the toddler to release frustration.
18. D. It is the developmental task of an 18-month-old toddler to explore and learn about the
environment. The respiratory complications associated with cystic fibrosis (which are present in
almost all children with cystic fibrosis) could prevent this development task from occurring.
19. C. The best diversion for a hospitalized child aged 2-3 years old would be anything that makes
noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.
20. B. An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the
installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.
21. D. In second grade a child needs to form a close relationships with peers.
22. B. A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks
many questions and in a situation such as this, could be expected to ask even more.
23. C. A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also
enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This
activity also provides the school-age child a needed opportunity to interact with others in the
absence of school and personal friends.
24. B. Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
25. D. An 8-month-old infant both recognizes and is fearful of strangers. This developmental
milestone is known as “stranger anxiety”.
26. A. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is
taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 –
36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a
slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in
concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4
degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has
occurred.
27. C. The woman must understand that, although the “fertile” period is approximately midcycle,
hormonal variations do occur and can result in early or late ovulations. To be effective, the
diaphragm should be inserted before every intercourse.
28. D. Although instructions vary among birth centers, primigravidas should seek care when regular
contractions are felt about 5 minutes apart, becoming longer and stronger.
29. B. Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during
arousal.
30. B. A wood surface provides the least chance for organisms to be present.
31. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant
with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is
always the infant’s first line of defense against infection.
32. B. A skin rash could indicate a concurrent infectious disease process in the infant. The
scheduled immunizations should be withheld until the status of the infant’s health can be
determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing
secretions are indications to withhold immunizations.
33. C. Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis.
Optimally, the third vaccination is given 6 months after the first.
34. B. Because of the high incidence of breast cancer, all women are considered to be at risk
regardless of health history.
35. B. Handwashing is the best way to prevent the spread of infection.
36. A. The purpose of the visit takes priority.
37. D. Frequent douching interferes with the natural protective barriers in the vagina that resist yeast
infection and should be avoided.
38. A. Completion for the recommended schedule of infant immunizations does not require a large
number of immunizations, but it also provides protection against multiple pediatric communicable
and infectious diseases.
39. C. This is appropriate foods that are high in iron and calcium but would not affect lactose
intolerance.
40. D. Intervention is needed when the woman thinks that she needs to wait only 6 months after
being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to
be free of TB before she should attempt pregnancy.
41. C. Salmonella organisms cause lower GI symptoms
42. C. It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and
rugs should be removed.
43. C. Condoms do not prevent ALL forms of sexually transmitted diseases.
44. A. Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s
sucking may stimulate uterine contractions.
45. C. Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The
itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually
occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does
not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing
before eating and after using the toilet can assist in breaking the cycle.
46. C. Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this
would lead to the nursing diagnosis of “altered comfort”.
47. C. Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is
frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and
occurs when pain prevents the child from touching the chin to the chest.
48. C. The primary goal is to prevent the spread of the disease to others. The child should experience
no complication. Although the health department may need to be notified at some point, it is no the
primary goal. It is also important to prevent discomfort as much as possible.
49. A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day.
When purulent discharge is present, saline eye irrigations or eye applications of warm compresses
may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be
instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are
closed.
50. D. The question asks about the immediate concern. The ABCs of community health care are
always attending to people’s basic needs of food, shelter, and clothing