Nle Compilation (2in1)

Nursing Board Practice Test Compilation
FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188 ANSWERS AND RATIONALE – MATERNAL AND CHILD MEDICAL SURGICAL NURSING Part 1 ........................... 475
Contents ANSWER KEY - FOUNDATION OF PROFESSIONAL HEALTH..................................................................... 366 ANSWERS and RATIONALES for MEDICAL SURGICAL
NURSING PRACTICE I: FOUNDATION OF NURSING NURSING PRACTICE.................................................. 199 MEDICAL SURGICAL NURSING ..................................... 372 NURSING Part 1 ........................................................ 479
PRACTICE .......................................................................... 4 COMMUNITY HEALTH NURSING AND CARE OF THE ANSWERS AND RATIONALE – MEDICAL SURGICAL MEDICAL SURGICAL NURSING Part 2 ........................... 481
NURSING PRACTICE II ..................................................... 15 MOTHER AND CHILD .................................................... 200 NURSING .................................................................. 377 MEDICAL SURGICAL NURSING Part 2 ....................... 485
NURSING PRACTICE III .................................................... 26 ANSWER KEY: COMMUNITY HEALTH NURSING AND PSYCHIATRIC NURSING ................................................ 379 ANSWERS and RATIONALES for MEDICAL SURGICAL
CARE OF THE MOTHER AND CHILD .......................... 211
NURSING PRACTICE IV.................................................... 36 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING NURSING Part 2 ........................................................ 489
Comprehensive Exam 1................................................ 213 ................................................................................. 384
NURSING PRACTICE V..................................................... 46 MEDICAL SURGICAL NURSING Part 3 ........................... 491
CARE OF CLIENTS WITH PHYSIOLOGIC AND FUNDAMENTALS OF NURSING PART 1 ........................ 387
TEST I - Foundation of Professional Nursing Practice .... 56 ANSWERS and RATIONALES for MEDICAL SURGICAL
PSYCHOSOCIAL ALTERATIONS...................................... 222
Answers and Rationale – Foundation of Professional FUNDAMENTALS OF NURSING PART 2 ........................ 392 NURSING Part 3 ........................................................ 495
ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC
Nursing Practice ......................................................... 66 ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 1 ...................................... 497
AND PSYCHOSOCIAL ALTERATIONS ......................... 234
TEST II - Community Health Nursing and Care of the NURSING PART 2 ...................................................... 397 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Nursing Practice Test V ................................................ 235
Mother and Child ........................................................... 74 FUNDAMENTALS OF NURSING PART 3 ........................ 401 Part 1 ........................................................................ 502
Nursing Practice Test V ................................................ 245
Answers and Rationale – Community Health Nursing ANSWERS and RATIONALES for FUNDAMENTALS OF PSYCHIATRIC NURSING Part 2 ...................................... 504
and Care of the Mother and Child ............................. 84 TEST I - Foundation of Professional Nursing Practice .. 255 NURSING PART 3 ...................................................... 405 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
TEST III - Care of Clients with Physiologic and Answers and Rationale – Foundation of Professional MATERNITY NURSING Part 1 ........................................ 409 Part 2 ........................................................................ 509
Psychosocial Alterations ................................................ 91 Nursing Practice ....................................................... 265
ANSWERS and RATIONALES for MATERNITY NURSING PSYCHIATRIC NURSING Part 3 ...................................... 512
Answers and Rationale – Care of Clients with TEST II - Community Health Nursing and Care of the Part 1 ........................................................................ 418 ANSWERS and RATIONALES for PSYCHIATRIC NURSING
Physiologic and Psychosocial Alterations ................ 102 Mother and Child ......................................................... 273
MATERNITY NURSING Part 2 ........................................ 428 Part 3 ........................................................................ 516
TEST IV - Care of Clients with Physiologic and Answers and Rationale – Community Health Nursing
Answer for maternity part 2 .................................... 433 PROFESSIONAL ADJUSTMENT ...................................... 519
Psychosocial Alterations .............................................. 111 and Care of the Mother and Child ........................... 283
PEDIATRIC NURSING .................................................... 434 LEADERSHIP and MANAGEMENT ................................. 522
Answers and Rationale – Care of Clients with TEST III - Care of Clients with Physiologic and
Physiologic and Psychosocial Alterations ................ 122 Psychosocial Alterations .............................................. 290 ANSWERS and RATIONALES for PEDIATRIC NURSING NURSING RESEARCH Part 1 .......................................... 532
................................................................................. 439 NURSING RESEARCH Part 2 .......................................... 542
TEST V - Care of Clients with Physiologic and Psychosocial Answers and Rationale – Care of Clients with
Alterations.................................................................... 133 Physiologic and Psychosocial Alterations ................ 301 COMMUNITY HEALTH NURSING Part 1........................ 444 Nursing Research Suggested Answer Key ................ 546
Answers and Rationale – Care of Clients with TEST IV - Care of Clients with Physiologic and COMMUNITY HEALTH NURSING Part 2........................ 454
Physiologic and Psychosocial Alterations ................ 144 Psychosocial Alterations .............................................. 310
PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations ................ 321
ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 158 TEST V - Care of Clients with Physiologic and Psychosocial
Alterations.................................................................... 332
PRACTICE TEST II Maternal and Child Health ............... 162
Answers and Rationale – Care of Clients with
ANSWERS AND RATIONALE – MATERNAL AND CHILD
Physiologic and Psychosocial Alterations ................ 343
HEALTH..................................................................... 167
PART III ......................................................................... 352
MEDICAL SURGICAL NURSING ..................................... 173
PRACTICE TEST I FOUNDATION OF NURSING .............. 352
ANSWERS AND RATIONALE – MEDICAL SURGICAL
NURSING .................................................................. 178 ANSWERS AND RATIONALE – FOUNDATION OF
NURSING .................................................................. 357
PSYCHIATRIC NURSING ................................................ 180
PRACTICE TEST II Maternal and Child Health ............... 361
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING
................................................................................. 185
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5. Benner’s “Proficient” nurse level is different

from the other levels in nursing expertise in the
NURSING PRACTICE I: FOUNDATION OF NURSING context of having:
PRACTICE a. the ability to organize and plan activities
b. having attained an advanced level of
SITUATION: Nursing is a profession. The nurse should education
have a background on the theories and foundation of c. a holistic understanding and perception
nursing as it influenced what is nursing today. of the client
d. intuitive and analytic ability in new
1. Nursing is the protection, promotion and situations
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering SITUATION: The nurse has been asked to administer an
through the diagnosis and treatment of human injection via Z TRACK technique. Questions 6 to 10 refer
response and advocacy in the care of the to this.
individuals, families, communities and the
population. This is the most accepted definition 6. The nurse prepares an IM injection for an adult
of nursing as defined by the: client using the Z track technique. 4 ml of
a. PNA medication is to be administered to the client.
b. ANA Which of the following site will you choose?
c. Nightingale a. Deltoid
d. Henderson b. Rectus femoris
c. Ventrogluteal
2. Advancement in Nursing leads to the d. Vastus lateralis
development of the Expanded Career Roles.
Which of the following is NOT an expanded 7. In infants 1 year old and below, which of the
career role for nurses? following is the site of choice for intramuscular
a. Nurse practitioner Injection?
b. Nurse Researcher a. Deltoid
c. Clinical nurse specialist b. Rectus femoris
d. Nurse anaesthesiologist c. Ventrogluteal
d. Vastus lateralis
3. The Board of Nursing regulated the Nursing
profession in the Philippines and is responsible 8. In order to decrease discomfort in Z track
for the maintenance of the quality of nursing in administration, which of the following is
the country. Powers and duties of the board of applicable?
nursing are the following, EXCEPT: a. Pierce the skin quickly and smoothly at
a. Issue, suspend, revoke certificates of a 90 degree angle
registration b. Inject the medication steadily at around
b. Issue subpoena duces tecum, ad 10 minutes per millilitre
testificandum c. Pull back the plunger and aspirate for 1
c. Open and close colleges of nursing minute to make sure that the needle did
d. Supervise and regulate the practice of not hit a blood vessel
nursing d. Pierce the skin slowly and carefully at a
90 degree angle
4. A nursing student or a beginning staff nurse who
has not yet experienced enough real situations 9. After injection using the Z track technique, the
to make judgments about them is in what stage nurse should know that she needs to wait for a
of Nursing Expertise? few seconds before withdrawing the needle and
a. Novice this is to allow the medication to disperse into
b. Newbie the muscle tissue, thus decreasing the client’s
c. Advanced Beginner discomfort. How many seconds should the nurse
d. Competent wait before withdrawing the needle?
a. 2 seconds
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b. 5 seconds that the patient smokes and drinks coffee. When What is the client’s blood pressure? to lungs. This can be avoided by:
c. 10 seconds taking the blood pressure of a client who a. 130/80 a. Cleaning teeth and mouth with cotton
d. 15 seconds recently smoked or drank coffee, how long b. 150/100 swabs soaked with mouthwash to avoid
should the nurse wait before taking the client’s c. 100/80 rinsing the buccal cavity
10. The rationale in using the Z track technique in an blood pressure for accurate reading? d. 150/100 b. swabbing the inside of the cheeks and
intramuscular injection is: a. 15 minutes lips, tongue and gums with dry cotton
a. It decreases the leakage of discolouring b. 30 minutes 20. In a client with a previous blood pressure of swabs
and irritating medication into the c. 1 hour 130/80 4 hours ago, how long will it take to c. use fingers wrapped with wet cotton
subcutaneous tissues d. 5 minutes release the blood pressure cuff to obtain an washcloth to rub inside the cheeks,
b. It will allow a faster absorption of the accurate reading? tongue, lips and ums
medication 15. While the client has pulse oximeter on his a. 10-20 seconds d. suctioning as needed while cleaning the
c. The Z track technique prevent irritation fingertip, you notice that the sunlight is shining b. 30-45 seconds buccal cavity
of the muscle on the area where the oximeter is. Your action c. 1-1.5 minutes
d. It is much more convenient for the nurse will be to: d. 3-3.5 minutes 25. Your client has difficulty of breathing and is
a. Set and turn on the alarm of the mouth breathing most of the time. This causes
SITUATION: A Client was rushed to the emergency room oximeter Situation: Oral care is an important part of hygienic dryness of the mouth with unpleasant odor. Oral
and you are his attending nurse. You are performing a b. Do nothing since there is no identified practices and promoting client comfort. hygiene is recommended for the client and in
vital sign assessment. problem addition, you will keep the mouth moistened by
c. Cover the fingertip sensor with a towel 21. An elderly client, 84 years old, is unconscious. using:
11. All of the following are correct methods in or bedsheet Assessment of the mouth reveals excessive a. salt solution
assessment of the blood pressure EXCEPT: d. Change the location of the sensor every dryness and presence of sores. Which of the b. petroleum jelly
a. Take the blood pressure reading on both four hours following is BEST to use for oral care? c. water
arms for comparison a. lemon glycerine d. mentholated ointment
b. Listen to and identify the phases of 16. The nurse finds it necessary to recheck the blood b. Mineral oil
Korotkoff’s sound pressure reading. In case of such re assessment, c. hydrogen peroxide Situation – Ensuring safety before, during and after a
c. Pump the cuff to around 50 mmHg the nurse should wait for a period of: d. Normal saline solution diagnostic procedure is an important responsibility of
above the point where the pulse is a. 15 seconds the nurse.
obliterated b. 1 to 2 minutes 22. When performing oral care to an unconscious
d. Observe procedures for infection control c. 30 minutes client, which of the following is a special 26. To help Fernan better tolerate the
d. 15 minutes consideration to prevent aspiration of fluids into bronchoscopy, you should instruct him to
12. You attached a pulse oximeter to the client. You the lungs? practice which of the following prior to the
know that the purpose is to: 17. If the arm is said to be elevated when taking the a. Put the client on a sidelying position procedure?
a. Determine if the client’s hemoglobin blood pressure, it will create a: with head of bed lowered a. Clenching his fist every 2 minutes
level is low and if he needs blood a. False high reading b. Keep the client dry by placing towel b. Breathing in and out through the nose
transfusion b. False low reading under the chin with his mouth open
b. Check level of client’s tissue perfusion c. True false reading c. Wash hands and observes appropriate c. Tensing the shoulder muscles while lying
c. Measure the efficacy of the client’s anti- d. Indeterminate infection control on his back
hypertensive medications d. Clean mouth with oral swabs in a careful d. Holding his breath periodically for 30
d. Detect oxygen saturation of arterial 18. You are to assessed the temperature of the and an orderly progression seconds
blood before symptoms of hypoxemia client the next morning and found out that he
develops ate ice cream. How many minutes should you 23. The advantages of oral care for a client include 27. Following a bronchoscopy, which of the
wait before assessing the client’s oral all of the following, EXCEPT: following complains to Fernan should be noted
13. After a few hours in the Emergency Room, The temperature? a. decreases bacteria in the mouth and as a possible complication:
client is admitted to the ward with an order of a. 10 minutes teeth a. Nausea and vomiting
hourly monitoring of blood pressure. The nurse b. 20 minutes b. reduces need to use commercial b. Shortness of breath and laryngeal
finds that the cuff is too narrow and this will c. 30 minutes mouthwash which irritate the buccal stridor
cause the blood pressure reading to be: d. 15 minutes mucosa c. Blood tinged sputum and coughing
a. inconsistent c. improves client’s appearance and self- d. Sore throat and hoarseness
b. low systolic and high diastolic 19. When auscultating the client’s blood pressure confidence
c. higher than what the reading should be the nurse hears the following: From 150 mmHg d. improves appetite and taste of food 28. Immediately after bronchoscopy, you instructed
d. lower than what the reading should be to 130 mmHg: Silence, Then: a thumping sound Fernan to:
continuing down to 100 mmHg; muffled sound 24. A possible problem while providing oral care to a. Exercise the neck muscles
14. Through the client’s health history, you gather continuing down to 80 mmHg and then silence. unconscious clients is the risk of fluid aspiration b. Refrain from coughing and talking
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c. Breathe deeply d. Weber’s test 38. Where would the nurse tape Eileen’s indwelling regulation is secreted in the:
d. Clear his throat catheter in order to reduce urethral irritation? a. Thyroid gland
34. A nurse is reviewing the arterial blood gas values a. to the patient’s inner thigh b. Parathyroid gland
29. Thoracentesis may be performed for cytologic of a client and notes that the ph is 7.31, Pco2 is b. to the patient’ buttocks c. Hypothalamus
study of pleural fluid. As a nurse your most 50 mmHg, and the bicarbonate is 27 mEq/L. The c. to the patient’s lower thigh d. Anterior pituitary gland
important function during the procedure is to: nurse concludes that which acid base d. to the patient lower abdomen
a. Keep the sterile equipment from disturbance is present in this client? 45. While Parathormone, a hormone that negates
contamination a. Respiratory acidosis 39. Which of the following menu is appropriate for the effect of calcitonin is secreted by the:
b. Assist the physician b. Metabolic acidosis one with low sodium diet? a. Thyroid gland
c. Open and close the three-way stopcock c. Respiratory alkalosis a. instant noodles, fresh fruits and ice tea b. Parathyroid gland
d. Observe the patient’s vital signs d. Metabolic alkalosis b. ham and cheese sandwich, fresh fruits c. Hypothalamus
and vegetables d. Anterior pituitary gland
30. Right after thoracentesis, which of the following 35. Allen’s test checks the patency of the: c. white chicken sandwich, vegetable
is most appropriate intervention? a. Ulnar artery salad and tea Situation: The staff nurse supervisor requests all the staff
a. Instruct the patient not to cough or deep b. Carotid artery d. canned soup, potato salad, and diet soda nurses to “brainstorm” and learn ways to instruct
breathe for two hours c. Radial artery diabetic clients on self-administration of insulin. She
b. Observe for symptoms of tightness of d. Brachial artery 40. How will you prevent ascending infection to wants to ensure that there are nurses available daily to
chest or bleeding Eileen who has an indwelling catheter? do health education classes.
c. Place an ice pack to the puncture site Situation 6: Eileen, 45 years old is admitted to the a. see to it that the drainage tubing
d. Remove the dressing to check for hospital with a diagnosis of renal calculi. She is touches the level of the urine 46. The plan of the nurse supervisor is an example of
bleeding experiencing severe flank pain, nauseated and with a b. change he catheter every eight hours a. in service education process
temperature of 39 0C. c. see to it that the drainage tubing does b. efficient management of human
Situation: Knowledge of the acid-base disturbance and not touch the level of the urine resources
the functions of the electrolytes is necessary to 36. Given the above assessment data, the most d. clean catheter may be used since c. increasing human resources
determine appropriate intervention and nursing actions. immediate goal of the nurse would be which of urethral meatus is not a sterile area d. primary prevention
the following?
31. A client with diabetes milletus has a blood a. Prevent urinary complication Situation: Hormones are secreted by the various glands 47. When Mrs. Guevarra, a nurse, delegates aspects
glucose level of 644 mg/dL. The nurse interprets b. maintains fluid and electrolytes in the body. Basic knowledge of the endocrine system is of the clients care to the nurse-aide who is an
that this client is at most risk for the c. Alleviate pain necessary. unlicensed staff, Mrs. Guevarra
development of which type of acid-base d. Alleviating nausea a. makes the assignment to teach the staff
imbalance? 41. Somatocrinin or the Growth hormone releasing member
a. Respiratory acidosis 37. After IVP a renal stone was confirmed, a left hormone is secreted by the: b. is assigning the responsibility to the
b. Respiratory alkalosis nephrectomy was done. Her post-operative a. Hypothalamus aide but not the accountability for
c. Metabolic acidosis order includes “daily urine specimen to be sent b. Posterior pituitary gland those tasks
d. Metabolic alkalosis to the laboratory”. Eileen has a foley catheter c. Anterior pituitary gland c. does not have to supervise or evaluate
attached to a urinary drainage system. How will d. Thyroid gland the aide
32. In a client in the health care clinic, arterial blood you collect the urine specimen? d. most know how to perform task
gas analysis gives the following results: pH 7.48, a. remove urine from drainage tube with 42. All of the following are secreted by the anterior delegated
PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. sterile needle and syringe and empty pituitary gland except:
The nurse interprets that the client has which urine from the syringe into the a. Somatotropin/Growth hormone 48. Connie, the new nurse, appears tired and
acid base disturbance? specimen container b. Thyroid stimulating hormone sluggish and lacks the enthusiasm she had six
a. Respiratory acidosis b. empty a sample urine from the c. Follicle stimulating hormone weeks ago when she started the job. The nurse
b. Metabolic acidosis collecting bag into the specimen d. Gonadotropin hormone releasing supervisor should
c. Respiratory alkalosis container hormone a. empathize with the nurse and listen to
d. Metabolic alkalosis c. Disconnect the drainage tube from the her
indwelling catheter and allow urine to 43. All of the following hormones are hormones b. tell her to take the day off
33. A client has an order for ABG analysis on radial flow from catheter into the specimen secreted by the Posterior pituitary gland except: c. discuss how she is adjusting to her new
artery specimens. The nurse ensures that which container. a. Vasopressin job
of the following has been performed or tested d. Disconnect the drainage from the b. Anti-diuretic hormone d. ask about her family life
before the ABG specimens are drawn? collecting bag and allow the urine to c. Oxytocin
a. Guthrie test flow from the catheter into the d. Growth hormone 49. Process of formal negotiations of working
b. Romberg’s test specimen container. conditions between a group of registered nurses
c. Allen’s test 44. Calcitonin, a hormone necessary for calcium and employer is
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a. grievance d. It should disclose previous diagnosis, d. Iron 75 mg/100 ml

b. arbitration prognosis and alternative treatments 60. A participant in the STROKE class asks what is a
c. collective bargaining available for the client risk factor of stroke. Your best response is: 65. Which of the following laboratory test result
d. strike a. “More red blood cells thicken blood indicate presence of an infectious process?
55. Delegation is the process of assigning tasks that and make clots more possible.” a. Erythrocyte sedimentation rate (ESR) 12
50. You are attending a certification on can be performed by a subordinate. The RN b. “Increased RBC count is linked to high mm/hr
cardiopulmonary resuscitation (CPR) offered and should always be accountable and should not cholesterol.” b. White blood cells (WBC) 18,000/mm3
required by the hospital employing you. This is lose his accountability. Which of the following is c. “More red blood cell increases c. Iron 90 g/100ml
a. professional course towards credits a role included in delegation? hemoglobin content.” d. Neutrophils 67%
b. in-service education a. The RN must supervise all delegated d. “High RBC count increases blood
c. advance training tasks pressure.” Situation: Pleural effusion is the accumulation of fluid in
d. continuing education b. After a task has been delegated, it is no the pleural space. Questions 66 to 70 refer to this.
longer a responsibility of the RN Situation: Recognition of normal values is vital in
Situation: As a nurse, you are aware that proper c. The RN is responsible and accountable assessment of clients with various disorders. 66. Which of the following is a finding that the nurse
documentation in the patient chart is your responsibility. for the delegated task in adjunct with will be able to assess in a client with Pleural
the delegate 61. A nurse is reviewing the laboratory test results effusion?
51. Which of the following is not a legally binding d. Follow up with a delegated task is for a client with a diagnosis of severe a. Reduced or absent breath sound at the
document but nevertheless very important in necessary only if the assistive personnel dehydration. The nurse would expect the base of the lungs, dyspnea, tachpynea
the care of all patients in any health care is not trustworthy hematocrit level for this client to be which of the and shortness of breath
setting? following? b. Hypoxemia, hypercapnea and
a. Bill of rights as provided in the Philippine Situation: When creating your lesson plan for a. 60% respiratory acidosis
constitution cerebrovascular disease or STROKE. It is important to b. 47% c. Noisy respiration, crackles, stridor and
b. Scope of nursing practice as defined by include the risk factors of stroke. c. 45% wheezing
RA 9173 d. 32% d. Tracheal deviation towards the affected
c. Board of nursing resolution adopting the 56. The most important risk factor is: side, increased fremitus and loud breath
code of ethics a. Cigarette smoking 62. A nurse is reviewing the electrolyte results of an sounds
d. Patient’s bill of rights b. binge drinking assigned client and notes that the potassium
c. Hypertension level is 5.6 mEq/L. Which of the following would 67. Thoracentesis is performed to the client with
52. A nurse gives a wrong medication to the client. d. heredity the nurse expect to note on the ECG as a result effusion. The nurse knows that the removal of
Another nurse employed by the same hospital as of this laboratory value? fluid should be slow. Rapid removal of fluid in
a risk manager will expect to receive which of 57. Part of your lesson plan is to talk about etiology a. ST depression thoracentesis might cause:
the following communication? or cause of stroke. The types of stroke based on b. Prominent U wave a. Pneumothorax
a. Incident report cause are the following EXCEPT: c. Inverted T wave b. Cardiovascular collapse
b. Nursing kardex a. Embolic stroke d. Tall peaked T waves c. Pleurisy or Pleuritis
c. Oral report b. diabetic stroke d. Hypertension
d. Complain report c. Hemorrhagic stroke 63. A nurse is reviewing the electrolyte results of an
d. thrombotic stroke assigned client and notes that the potassium 68. 3 Days after thoracentesis, the client again
53. Performing a procedure on a client in the level is 3.2 mEq/L. Which of the following would exhibited respiratory distress. The nurse will
absence of an informed consent can lead to 58. Hemmorhagic stroke occurs suddenly usually the nurse expect to note on the ECG as a result know that pleural effusion has reoccurred when
which of the following charges? when the person is active. All are causes of of this laboratory value? she noticed a sharp stabbing pain during
a. Fraud hemorrhage, EXCEPT: a. U waves inspiration. The physician ordered a closed tube
b. Harassment a. phlebitis b. Elevated T waves thoracotomy for the client. The nurse knows
c. Assault and battery b. damage to blood vessel c. Absent P waves that the primary function of the chest tube is to:
d. Breach of confidentiality c. trauma d. Elevated ST Segment a. Restore positive intrathoracic pressure
d. aneurysm b. Restore negative intrathoracic pressure
54. Which of the following is the essence of 64. Dorothy underwent diagnostic test and the c. To visualize the intrathoracic content
informed consent? 59. The nurse emphasizes that intravenous drug result of the blood examination are back. On d. As a method of air administration via
a. It should have a durable power of abuse carries a high risk of stroke. Which drug is reviewing the result the nurse notices which of ventilator
attorney closely linked to this? the following as abnormal finding?
b. It should have coverage from an a. Amphetamines a. Neutrophils 60% 69. The chest tube is functioning properly if:
insurance company b. shabu b. White blood cells (WBC) 9000/mm a. There is an oscillation
c. It should respect the client’s freedom c. Cocaine c. Erythrocyte sedimentation rate (ESR) is b. There is no bubbling in the drainage
from coercion d. Demerol 39 mm/hr bottle
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c. There is a continuous bubbling in the b. Not takes sides, remain neutral and fair
waterseal 75. This form of Health Insurance provides c. Assume that ethical questions are the 85. Based on the Code of Ethics for Filipino Nurses,
d. The suction control bottle has a comprehensive prepaid health services to responsibility of the health team what is regarded as the hallmark of nursing
continuous bubbling enrollees for a fixed periodic payment. d. Be accountable for his or her own responsibility and accountability?
a. Health Maintenance Organization actions a. Human rights of clients, regardless of
70. In a client with pleural effusion, the nurse is b. Medicare creed and gender
instructing appropriate breathing technique. c. Philippine Health Insurance Act 81. Why is there an ethical dilemma? b. The privilege of being a registered
Which of the following is included in the d. Hospital Maintenance Organization a. the choices involved do not appear to be professional nurse
teaching? clearly right or wrong c. Health, being a fundamental right of
a. Breath normally Situation: Nursing ethics is an important part of the b. a client’s legal right co-exist with the every individual
b. Hold the breath after each inspiration nursing profession. As the ethical situation arises, so is nurse’s professional obligation d. Accurate documentation of actions and
for 1 full minute the need to have an accurate and ethical decision c. decisions has to be made based on outcomes
c. Practice abdominal breathing making. societal norms.
d. Inhale slowly and hold the breath for 3 d. decisions has to be mad quickly, often Situation: As a profession, nursing is dynamic and its
to 5 seconds after each inhalation 76. The purpose of having a nurses’ code of ethics is: under stressful conditions practice is directed by various theoretical models. To
a. Delineate the scope and areas of nursing demonstrate caring behaviour, the nurse applies various
SITUATION: Health care delivery system affects the practice 82. According to the code of ethics, which of the nursing models in providing quality nursing care.
health status of every filipino. As a Nurse, Knowledge of b. identify nursing action recommended for following is the primary responsibility of the
this system is expected to ensure quality of life. specific health care situations nurse? 86. When you clean the bedside unit and regularly
c. To help the public understand a. Assist towards peaceful death attend to the personal hygiene of the patient as
71. When should rehabilitation commence? professional conduct expected of b. Health is a fundamental right well as in washing your hands before and after a
a. The day before discharge nurses c. Promotion of health, prevention of procedure and in between patients, you indent
b. When the patient desires d. To define the roles and functions of the illness, alleviation of suffering and to facilitate the body’s reparative processes.
c. Upon admission health care givers, nurses, clients restoration of health Which of the following nursing theory are you
d. 24 hours after discharge d. Preservation of health at all cost applying in the above nursing action?
77. The principles that govern right and proper a. Hildegard Peplau
72. What exemplified the preventive and promotive conduct of a person regarding life, biology and 83. Which of the following is TRUE about the Code b. Dorothea Orem
programs in the hospital? the health professionals is referred to as: of Ethics of Filipino Nurses, except: c. Virginia Henderson
a. Hospital as a center to prevent and a. Morality a. The Philippine Nurses Association for d. Florence Nightingale
control infection b. Religion being the accredited professional
b. Program for smokers c. Values organization was given the privilege to 87. A communication skill is one of the important
c. Program for alcoholics and drug addicts d. Bioethics formulate a Code of Ethics for Nurses competencies expected of a nurse. Interpersonal
d. Hospital Wellness Center which the Board of Nursing process is viewed as human to human
78. A subjective feeling about what is right or wrong promulgated relationship. This statement is an application of
73. Which makes nursing dynamic? is said to be: b. Code for Nurses was first formulated in whose nursing model?
a. Every patient is a unique physical, a. Morality 1982 published in the Proceedings of the a. Joyce Travelbee
emotional, social and spiritual being b. Religion Third Annual Convention of the PNA b. Martha Rogers
b. The patient participate in the overall c. Values House of Delegates c. Callista Roy
nursing care plan d. Bioethics c. The present code utilized the Code of d. Imogene King
c. Nursing practice is expanding in the light Good Governance for the Professions in
of modern developments that takes 79. Values are said to be the enduring believe about the Philippines 88. The statement “the health status of an individual
place a worth of a person, ideas and belief. If Values d. Certificates of Registration of registered is constantly changing and the nurse must be
d. The health status of the patient is are going to be a part of a research, this is nurses may be revoked or suspended for cognizant and responsive to these changes” best
constantly changing and the nurse must categorized under: violations of any provisions of the Code explains which of the following facts about
be cognizant and responsive to these a. Qualitative of Ethics. nursing?
changes b. Experimental a. Dynamic
c. Quantitative 84. Violation of the code of ethics might equate to b. Client centred
74. Prevention is an important responsibility of the d. Non Experimental the revocation of the nursing license. Who c. Holistic
nurse in: revokes the license? d. Art
a. Hospitals 80. The most important nursing responsibility where a. PRC
b. Community ethical situations emerge in patient care is to: b. PNA 89. Virginia Henderson professes that the goal of
c. Workplace a. Act only when advised that the action is c. DOH nursing is to work interdependently with other
d. All of the above ethically sound d. BON health care working in assisting the patient to
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gain independence as quickly as possible. Which include: b. Medicine preparation is correct

of the following nursing actions best a. Prescription of the doctor to the c. Position of the client is correct
demonstrates this theory in taking care of a 94 patient’s illness d. Consent is signed by relative and
year old client with dementia who is totally b. Plan of care for patient physician
immobile? c. Patient’s perception of one’s illness
a. Feeds the patient, brushes his teeth, d. Nursing problem and Nursing diagnosis 99. As a nurse, you know that the position for June
gives the sponge bath before thoracentesis is:
b. Supervise the watcher in rendering 94. The medical records that are organized into a. Orthopneic
patient his morning care separate section from doctors or nurses has b. Low fowlers
c. Put the patient in semi fowler’s position, more disadvantages than advantages. This is c. Knee-chest
set the over bed table so the patient can classified as what type of recording? d. Sidelying position on the affected side
eat by himself, brush his teeth and a. POMR
sponge himself b. Modified POMR 100. Which of the following anaesthetics drug is used
d. Assist the patient to turn to his sides and c. SOAPIE for thoracentesis?
allow him to brush and feed himself only d. SOMR a. Procaine 2%
when he feels ready b. Demerol 75 mg
95. Which of the following is the advantage of SOMR c. Valium 250 mg
90. In the self-care deficit theory by Dorothea Orem, or Traditional recording? d. Phenobartbital 50 mg
nursing care becomes necessary when a patient a. Increases efficiency in data gathering
is unable to fulfil his physiological, psychological b. Reinforces the use of the nursing
and social needs. A pregnant client needing process
prenatal check-up is classified as: c. The caregiver can easily locate proper
a. Wholly compensatory section for making charting entries
b. Supportive Educative d. Enhances effective communication
c. Partially compensatory among health care team members
d. Non compensatory
Situation: June is a 24 year old client with symptoms of
Situation: Documentation and reporting are just as dyspnea, absent breath sounds on the right lung and
important as providing patient care, As such, the nurse chest x ray revealed pleural effusion. The physician will
must be factual and accurate to ensure quality perform thoracentesis.
documentation and reporting.
96. Thoracentesis is useful in treating all of the
91. Health care reports have different purposes. The following pulmonary disorders except:
availability of patients’ record to all health team a. Hemothorax
members demonstrates which of the following b. Hydrothorax
purposes: c. Tuberculosis
a. Legal documentation d. Empyema
b. Research
c. Education 97. Which of the following psychological preparation
d. Vehicle for communication is not relevant for him?
a. Telling him that the gauge of the needle
92. When a nurse commits medication error, she and anesthesia to be used
should accurately document client’s response b. Telling him to keep still during the
and her corresponding action. This is very procedure to facilitate the insertion of
important for which of the following purposes: the needle in the correct place
a. Research c. Allow June to express his feelings and
b. Legal documentation concerns
c. Nursing Audit d. Physician’s explanation on the purpose
d. Vehicle for communication of the procedure and how it will be done
93. POMR has been widely used in many teaching 98. Before thoracentesis, the legal consideration you
hospitals. One of its unique features is SOAPIE must check is:
charting. The P in SOAPIE charting should a. Consent is signed by the client
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D. Follicle stimulating hormone requirements of pregnancies related to 15. While talking with Susan, 2 new patients arrived
lack of information sources and they are covered with large towels and the
NURSING PRACTICE II 5. The following month, Mariah suspects she is nurse noticed that there are many cameraman
pregnant. Her urine is positive for Human 10. Which of the following interventions will likely and news people outside of the OPD. Upon
Situation: Mariah is a 31 year old lawyer who has been chorionic gonadotrophin. Which structure ensure compliance of Mariah? assessment the nurse noticed that both of them
married for 6 months. She consults you for guidance in produces Hcg? A. Incorporate her food preferences that are still nude and the male client’s penis is still
relation with her menstrual cycle and her desire to get A. Pituitary gland are adequately nutritious in her meal inside the female client’s vagina and the male
pregnant. B. Trophoblastic cells of the embryo plan client said that “I can’t pull it”. Vaginismus was
C. Uterine deciduas B. Consistently counsel toward optimum your first impression. You know that The
1. She wants to know the length of her menstrual D. Ovarian follicles nutritional intake psychological cause of Vaginismus is related to:
cycle. Her previous menstrual period is October C. Respect her right to reject dietary A. The male client inserted the penis too
22 to 26. Her LMB is November 21. Which of the Situation: Mariah came back and she is now pregnant. information if she chooses deeply that it stimulates vaginal closure
following number of days will be your correct D. Inform her of the adverse effects of B. The penis was too large that is why the
response? 6. At 5 month gestation, which of the following inadequate nutrition to her fetus vagina triggered its defense to attempt
A. 29 fetal development would probably be achieve? to close it
B. 28 A. Fetal movement are felt by Mariah Situation: Susan is a patient in the clinic where you work. C. The vagina does not want to be
C. 30 B. Vernix caseosa covers the entire body She is inquiring about pregnancy. penetrated
D. 31 C. Viable if delivered within this period D. It is due to learning patterns of the
D. Braxton hicks contractions are observed 11. Susan tells you she is worried because she female client where she views sex as
2. You advised her to observe and record the signs develops breasts later than most of her friends. bad or sinful
of Ovulation. Which of the following signs will 7. The nurse palpates the abdomen of Mariah. Breast development is termed as:
she likely note down? Now At 5 month gestation, What level of the A. Adrenarche Situation: Overpopulation is one problem in the
1. A 1 degree Fahrenheit rise in basal body abdomen can the fundic height be palpated? B. Thelarche Philippines that causes economic drain. Most Filipinos
temperature A. Symphysis pubis C. Mamarche are against in legalizing abortion. As a nurse, Mastery of
2. Cervical mucus becomes copious and B. Midpoint between the umbilicus and the D. Menarche contraception is needed to contribute to the society and
clear xiphoid process economic growth.
3. One pound increase in weight C. Midpoint between the symphysis pubis 12. Kevin, Susan’s husband tells you that he is
4. Mittelschmerz and the umbilicus considering vasectomy After the birth of their 16. Supposed that Dana, 17 years old, tells you she
A. 1, 2, 4 D. Umbilicus new child. Vasectomy involves the incision of wants to use fertility awareness method of
B. 1, 2, 3 which organ? contraception. How will she determine her
C. 2, 3, 4 8. She worries about her small breasts, thinking A. The testes fertile days?
D. 1, 3, 4 that she probably will not be able to breastfeed B. The epididymis A. She will notice that she feels hot, as if
her baby. Which of the following responses of C. The vas deferens she has an elevated temperature.
3. You instruct Mariah to keep record of her basal the nurse is correct? D. The scrotum B. She should assess whether her cervical
temperature every day, which of the following A. “The size of your breast will not affect mucus is thin, copious, clear and
instructions is incorrect? your lactation” 13. On examination, Susan has been found of having watery.
A. If coitus has occurred; this should be B. “You can switch to bottle feeding” a cystocele. A cystocele is: C. She should monitor her emotions for
reflected in the chart C. “You can try to have exercise to increase A. A sebaceous cyst arising from the vulvar sudden anger or crying
B. It is best to have coitus on the evening the size of your breast” fold D. She should assess whether her breasts
following a drop in BBT to become D. “Manual expression of milk is possible” B. Protrusion of intestines into the vagina feel sensitive to cool air
pregnant C. Prolapse of the uterus into the vagina
C. Temperature should be taken 9. She tells the nurse that she does not take milk D. Herniation of the bladder into the 17. Dana chooses to use COC as her family planning
immediately after waking and before regularly. She claims that she does not want to vaginal wall method. What is the danger sign of COC you
getting out of bed gain too much weight during her pregnancy. would ask her to report?
D. BBT is lowest during the secretory Which of the following nursing diagnosis is a 14. Susan typically has menstrual cycle of 34 days. A. A stuffy or runny nose
phase priority? She told you she had coitus on days 8, 10, 15 and B. Slight weight gain
A. Potential self-esteem disturbance 20 of her menstrual cycle. Which is the day on C. Arthritis like symptoms
4. She reports an increase in BBT on December 16. related to physiologic changes in which she is most likely to conceive? D. Migraine headache
Which hormone brings about this change in her pregnancy A. 8th day
BBT? B. Ineffective individual coping related to B. Day 15 18. Dana asks about subcutaneous implants and she
A. Estrogen physiologic changes in pregnancy C. 10th day asks, how long will these implants be effective.
B. Gonadotropine C. Fear related to the effects of pregnancy D. Day 20 Your best answer is:
C. Progesterone D. Knowledge deficit regarding nutritional A. One month
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B. Five years B. have increased hepatic, renal and D. Chronic poverty

C. Twelve months 23. Another client named Lilia is diagnosed as having gastrointestinal function
D. 10 years endometriosis. This condition interferes with C. have increased sensory perception 34. Which of the following signs and symptoms
fertility because: D. mobilize drugs more rapidly would you most likely find when assessing and
19. Dana asks about female condoms. Which of the A. Endometrial implants can block the infant with Arnold-Chiari malformation?
following is true with regards to female fallopian tubes 28. The elderly patient is at higher risk for urinary A. Weakness of the leg muscles, loss of
condoms? B. The uterine cervix becomes inflamed incontinence because of: sensation in the legs, and restlessness
A. The hormone the condom releases and swollen A. increased glomerular filtration B. Difficulty swallowing, diminished or
might cause mild weight gain C. The ovaries stop producing adequate B. decreased bladder capacity absent gag reflex, and respiratory
B. She should insert the condom before estrogen C. diuretic use distress
any penile penetration D. Pressure on the pituitary leads to D. dilated urethra C. Difficulty sleeping, hypervigilant, and an
C. She should coat the condom with decreased FSH levels arching of the back
spermicide before use 29. Which of the following is the MOST COMMON D. Paradoxical irritability, diarrhea, and
D. Female condoms, unlike male condoms, 24. Lilia is scheduled to have a sign of infection among the elderly? vomiting.
are reusable hysterosalphingogram. Which of the following A. decreased breath sounds with crackles
instructions would you give her regarding this B. pain 35. A parent calls you and frantically reports that her
20. Dana has asked about GIFT procedure. What procedure? C. fever child has gotten into her famous ferrous sulfate
makes her a good candidate for GIFT? A. She will not be able to conceive for 3 D. change in mental status pills and ingested a number of these pills. Her
A. She has patent fallopian tubes, so months after the procedure child is now vomiting, has bloody diarrhea, and is
fertilized ova can be implanted on them B. The sonogram of the uterus will reveal 30. Priorities when caring for the elderly trauma complaining of abdominal pain. You will tell the
B. She is RH negative, a necessary any tumors present patient: mother to:
stipulation to rule out RH incompatibility C. Many women experience mild bleeding A. circulation, airway, breathing A. Call emergency medical services (EMS)
C. She has normal uterus, so the sperm can as an after effect B. airway, breathing, disability (neurologic) and get the child to the emergency room
be injected through the cervix into it D. She may feel some cramping when the C. disability (neurologic), airway, breathing B. Relax because these symptoms will pass
D. Her husband is taking sildenafil, so all dye is inserted D. airway, breathing, circulation and the child will be fine
sperms will be motile C. Administer syrup of ipecac
25. Lilia’s cousin on the other hand, knowing nurse 31. Preschoolers are able to see things from which D. Call the poison control center
Situation: Nurse Lorena is a Family Planning and Lorena’s specialization asks what artificial of the following perspectives?
Infertility Nurse Specialist and currently attends to insemination by donor entails. Which would be A. Their peers 36. A client says she heard from a friend that you
FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. your best answer if you were Nurse Lorena? B. Their own and their mother’s stop having periods once you are on the “pill”.
The following conditions pertain to meeting the nursing A. Donor sperm are introduced vaginally C. Their own and their caregivers’ The most appropriate response would be:
needs of this particular population group. into the uterus or cervix D. Only their own A. “The pill prevents the uterus from
B. Donor sperm are injected intra- making such endometrial lining, that is
21. Dina, 17 years old, asks you how a tubal ligation abdominally into each ovary 32. In conflict management, the win-win approach why periods may often be scant or
prevents pregnancy. Which would be the best C. Artificial sperm are injected vaginally to occurs when: skipped occasionally.”
answer? test tubal patency A. There are two conflicts and the parties B. “If your friend has missed her period,
A. Prostaglandins released from the cut D. The husband’s sperm is administered agree to each one she should stop taking the pills and get a
fallopian tubes can kill sperm intravenously weekly B. Each party gives in on 50% of the pregnancy test as soon as possible.”
B. Sperm cannot enter the uterus because disagreements making up the conflict C. “The pill should cause a normal
the cervical entrance is blocked. Situation: You are assigned to take care of a group of C. Both parties involved are committed to menstrual period every month. It
C. Sperm can no longer reach the ova, patients across the lifespan. solving the conflict sounds like your friend has not been
because the fallopian tubes are blocked D. The conflict is settled out of court so the taking the pills properly.”
D. The ovary no longer releases ova as 26. Pain in the elder persons requires careful legal system and the parties win D. “Missed period can be very dangerous
there is nowhere for them to go. assessment because they: and may lead to the formation of
A. experienced reduce sensory perception 33. According to the social-interactional perspective precancerous cells.”
22. The Dators are a couple undergoing testing for B. have increased sensory perception of child abuse and neglect, four factors place the
infertility. Infertility is said to exist when: C. are expected to experience chronic pain family members at risk for abuse. These risk 37. The nurse assessing newborn babies and infants
A. A woman has no uterus D. have a decreased pain threshold factors are the family members at risk for abuse. during their hospital stay after birth will notice
B. A woman has no children These risk factors are the family itself, the which of the following symptoms as a primary
C. A couple has been trying to conceive for 27. Administration of analgesics to the older persons caregiver, the child, and manifestation of Hirschsprung’s disease?
1 year requires careful patient assessment because A. The presence of a family crisis A. A fine rash over the trunk
D. A couple has wanted a child for 6 older people: B. The national emphasis on sex B. Failure to pass meconium during the
months A. are more sensitive to drugs C. Genetics first 24 to 48 hours after birth
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C. The skin turns yellow and then brown release C. The urine dipstick showing glucose in the
over the first 48 hours of life B. a woman is less able to keep the urine for 3 days, extreme thirst, increase 51. If a child with diarrhea registers two signs in the
D. High-grade fever laceration clean because of her fatigue in urine output, and a moon face. yellow row in the IMCI chart, we can classify the
C. healing is limited during pregnancy so D. A temperature of 37.8 degrees (100 patient as:
38. A client is 7 months pregnant and has just been these will not heal until after birth degrees F), flank pain, burning A. Moderate dehydration
diagnosed as having a partial placenta previa. D. increased bleeding can occur from frequency, urgency on voiding, and B. Severe dehydration
She is stable and has minimal spotting and is uterine pressure on leg veins cloudy urine. C. Some dehydration
being sent home. Which of these instructions to D. No dehydration
the client may indicate a need for further 43. In working with the caregivers of a client with an 47. The nurse is working with an adolescent who
teaching? acute or chronic illness, the nurse would: complains of being lonely and having a lack of 52. Celeste has had diarrhea for 8 days. There is no
A. Maintain bed rest with bathroom A. Teach care daily and let the caregivers fulfillment in her life. This adolescent shies away blood in the stool, he is irritable, his eyes are
privileges do a return demonstration just before from intimate relationships at times yet at other sunken, the nurse offers fluid to Celeste and he
B. Avoid intercourse for three days. discharge times she appears promiscuous. The nurse will drinks eagerly. When the nurse pinched the
C. Call if contractions occur. B. Difficulty swallowing, diminished or likely work with this adolescent in which of the abdomen it goes back slowly. How will you
D. Stay on left side as much as possible absent gag reflex, and respiratory following areas? classify Celeste’s illness?
when lying down. distress. A. Isolation A. Moderate dehydration
C. Difficulty sleeping, hypervigilant, and an B. Lack of fulfillment B. Severe dehydration
39. A woman has been rushed to the hospital with arching of the back C. Loneliness C. Some dehydration
ruptured membrane. Which of the following D. Paradoxical irritability, diarrhea, and D. Identity D. No dehydration
should the nurse check first? vomiting
A. Check for the presence of infection 48. The use of interpersonal decision making, 53. A child who is 7 weeks has had diarrhea for 14
B. Assess for Prolapse of the umbilical 44. Which of the following roles BEST exemplifies psychomotor skills, and application of days but has no sign of dehydration is classified
cord the expanded role of the nurse? knowledge expected in the role of a licensed as:
C. Check the maternal heart rate A. Circulating nurse in surgery health care professional in the context of public A. Persistent diarrhea
D. Assess the color of the amniotic fluid B. Medication nurse health welfare and safety is an example of: B. Dysentery
C. Obstetrical nurse A. Delegation C. Severe dysentery
40. The nurse notes that the infant is wearing a D. Pediatric nurse practitioner B. Responsibility D. Severe persistent diarrhea
plastic-coated diaper. If a topical medication C. Supervision
were to be prescribed and it were to go on the 45. According to DeRosa and Kochura’s (2006) D. Competence 54. The child with no dehydration needs home
stomachs or buttocks, the nurse would teach the article entitled “Implement Culturally Competent treatment. Which of the following is not
caregivers to: Health Care in your work place,” cultures have 49. The painful phenomenon known as “back labor” included in the rules for home treatment in this
A. avoid covering the area of the topical different patterns of verbal and nonverbal occurs in a client whose fetus in what position? case?
medication with the diaper communication. Which difference does? A. Brow position A. Forced fluids
B. avoid the use of clothing on top of the A. NOT necessarily belong? B. Breech position B. When to return
diaper B. Personal behavior C. Right Occipito-Anterior Position C. Give vitamin A supplement
C. put the diaper on as usual C. Subject matter D. Left Occipito-Posterior Position D. Feeding more
D. apply an icepack for 5 minutes to the D. Eye contact
outside of the diaper E. Conversational style 50. FOCUS methodology stands for: 55. Fever as used in IMCI includes:
A. Focus, Organize, Clarify, Understand A. Axillary temperature of 37.5 or higher
41. Which of the following factors is most important 46. You are the nurse assigned to work with a child and Solution B. Rectal temperature of 38 or higher
in determining the success of relationships used with acute glomerulonephritis. By following the B. Focus, Opportunity, Continuous, Utilize, C. Feeling hot to touch
in delivering nursing care? prescribed treatment regimen, the child Substantiate D. All of the above
A. Type of illness of the client experiences a remission. You are now checking C. Focus, Organize, Clarify, Understand, E. A and C only
B. Transference and counter transference to make sure the child does not have a relapse. Substantiate
C. Effective communication Which finding would most lead you to the D. Focus, Opportunity, Continuous Situation: Prevention of Dengue is an important nursing
D. Personality of the participants conclusion that a relapse is happening? (process), Understand, Solution responsibility and controlling it’s spread is a priority once
A. Elevated temperature, cough, sore outbreak has been observed.
42. Grace sustained a laceration on her leg from throat, changing complete blood count SITUATION: The infant and child mortality rate in the low
automobile accident. Why are lacerations of (CBC) with diiferential to middle income countries is ten times higher than 56. An important role of the community health
lower extremities potentially more serious B. A urine dipstick measurement of 2+ industrialized countries. In response to this, the WHO nurse in the prevention and control of Dengue
among pregnant women than other? proteinuria or more for 3 days, or the and UNICEF launched the protocol Integrated H-fever includes:
A. lacerations can provoke allergic child found to have 3-4+ proteinutria Management of Childhood Illnesses to reduce the A. Advising the elimination of vectors by
responses due to gonadotropic hormone plus edema. morbidity and mortality against childhood illnesses. keeping water containers covered
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B. Conducting strong health education health worker should first: function of the community health nurse? C. 30 breaths per minute or more
drives/campaign directed towards A. Identify the myths and misconceptions A. Conduct community assemblies. D. 60 breaths per minute
proper garbage disposal prevailing in the community B. Referral to cancer specialist those clients
C. Explaining to the individuals, families, B. Identify the source of these myths and with symptoms of cancer. 73. Nina, the 2nd child has diarrhea for 5 days.
groups and community the nature of misconceptions C. Use the nine warning signs of cancer as There is no blood in the stool. She is irritable,
the disease and its causation C. Explain how and why these myths came parameters in our process of detection, and her eyes are sunken. The nurse offered
D. Practicing residual spraying with about control and treatment modalities. fluids and and the child drinks eagerly. How
insecticides D. Select the appropriate IEC strategies to D. Teach woman about proper/correct would you classify Nina’s illness?
correct them nutrition. A. Some dehydration
57. Community health nurses should be alert in B. Severe dehydration
observing a Dengue suspect. The following is 62. How many percent of measles are prevented by 68. Who among the following are recipients of the C. Dysentery
NOT an indicator for hospitalization of H-fever immunization at 9 months of age? secondary level of care for cancer cases? D. No dehydration
suspects? A. 80% A. Those under early case detection
A. Marked anorexia, abdominal pain and B. 99% B. Those under post case treatment 74. Nina’s treatment should include the following
vomiting C. 90% C. Those scheduled for surgery EXCEPT:
B. Increasing hematocrit count D. 95% D. Those undergoing treatment A. reassess the child and classify him for
C. Cough of 30 days dehydration
D. Persistent headache 63. After TT3 vaccination a mother is said to be 69. Who among the following are recipients of the B. for infants under 6 months old who are
protected to tetanus by around: tertiary level of care for cancer cases? not breastfed, give 100-200 ml clean
58. The community health nurses’ primary concern A. 80% A. Those under early treatment water as well during this period
in the immediate control of hemorrhage among B. 99% B. Those under early detection C. Give in the health center the
patients with dengue is: C. 85% C. Those under supportive care recommended amount of ORS for 4
A. Advising low fiber and non-fat diet D. 90% D. Those scheduled for surgery hours.
B. Providing warmth through light weight D. Do not give any other foods to the child
covers 64. If ever convulsions occur after administering 70. In Community Health Nursing, despite the for home treatment
C. Observing closely the patient for vital DPT, what should the nurse best suggest to the availability and use of many equipment and
signs leading to shock mother? devices to facilitate the job of the community 75. While on treatment, Nina 18 months old
D. Keeping the patient at rest A. Do not continue DPT vaccination health nurse, the best tool any nurse should be weighed 18 kgs. and her temperature registered
anymore wel be prepared to apply is a scientific approach. at 37 degrees C. Her mother says she developed
59. Which of these signs may NOT be REGARDED as B. Advise mother to comeback after 1 week This approach ensures quality of care even at the cough 3 days ago. Nina has no general danger
a truly positive signs indicative of Dengue H- C. Give DT instead of DPT community setting. This is nursing parlance is signs. She has 45 breaths/minute, no chest in-
fever? D. Give pertussis of the DPT and remove DT nothing less than the: drawing, no stridor. How would you classify
A. Prolonged bleeding time A. nursing diagnosis Nina’s manifestation?
B. Appearance of at least 20 petechiae 65. These vaccines are given 3 doses at one month B. nursing research A. No pneumonia
within 1cm square intervals: C. nursing protocol B. Pneumonia
C. Steadily increasing hematocrit count A. DPT, BCG, TT D. nursing process C. Severe pneumonia
D. Fall in the platelet count B. OPV, HEP. B, DPT D. Bronchopneumonia
C. DPT, TT, OPV Situation – Two children were brought to you. One with
60. Which of the following is the most important D. Measles, OPV, DPT chest indrawing and the other had diarrhea. The 76. Carol is 15 months old and weighs 5.5 kgs and it
treatment of patients with Dengue H-fever? following questions apply: is her initial visit. Her mother says that Carol is
A. Give aspirin for fever Situation – With the increasing documented cases of not eating well and unable to breastfeed, he has
B. Replacement of body fluids CANCER the best alternative to treatment still remains to 71. Using Integrated Management and Childhood no vomiting, has no convulsion and not
C. Avoid unnecessary movement of patient be PREVENTION. The following conditions apply. Illness (IMCI) approach, how would you classify abnormally sleepy or difficult to awaken. Her
D. Ice cap over the abdomen in case of the 1st child? temperature is 38.9 deg C. Using the integrated
melena 66. Which among the following is the primary focus A. Bronchopneumonia management of childhood illness or IMCI
of prevention of cancer? B. Severe pneumonia strategy, if you were the nurse in charge of
Situation: Health education and Health promotion is an A. Elimination of conditions causing cancer C. No pneumonia : cough or cold Carol, how will you classify her illness?
important part of nursing responsibility in the B. Diagnosis and treatment D. Pneumonia A. a child at a general danger sign
community. Immunization is a form of health promotion C. Treatment at early stage B. severe pneumonia
that aims at preventing the common childhood illnesses. D. Early detection 72. The 1st child who is 13 months has fast C. very severe febrile disease
breathing using IMCI parameters he has: D. severe malnutrition
61. In correcting misconceptions and myths about 67. In the prevention and control of cancer, which of A. 40 breaths per minute or more
certain diseases and their management, the the following activities is the most important B. 50 breaths per minute 77. Why are small for gestational age newborns at
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risk for difficulty maintaining body temperature? B. give the child more fluids B. Speaker, listener and reply D. Parasites
A. their skin is more susceptible to C. continue feeding the child C. Facial expression, tone of voice and
conduction of cold D. inform when to return to the health gestures 93. You are assigned in a private room of Mike.
B. they are preterm so are born relatively center D. Message, sender, channel, receiver and Which procedure should be of outmost
small in size feedback importance;
C. they do not have as many fat stored as 83. Ms. Jordan, RN, believes that a patient should be A. Alcohol wash
other infants treated as individual. This ethical principle that 88. The extent of burns in children are normally B. Washing Isolation
D. they are more active than usual so they the patient referred to: assessed and expressed in terms of: C. Universal precaution
throw off comes A. beneficence A. The amount of body surface that is D. Gloving technique
B. respect for person unburned
78. Oxytocin is administered to Rita to augment C. nonmaleficence B. Percentages of total body surface area 94. What primary health teaching would you give to
labor. What are the first symptoms of water D. autonomy (TBSA) mike;
intoxication to observe for during this C. How deep the deepest burns are A. Daily exercise
procedure? 84. When patients cannot make decisions for D. The severity of the burns on a 1 to 5 B. reverse isolation
A. headache and vomiting themselves, the nurse advocate relies on the burn scale. C. Prevent infection
B. a high choking voice ethical principle of: D. Proper nutrition
C. a swollen tender tongue A. justice and beneficence 89. The school nurse notices a child who is wearing
D. abdominal bleeding and pain B. beneficence and nonmaleficence old, dirty, poor-fitting clothes; is always hungry; 95. Exercise precaution must be taken to protect
C. fidelity and nonmaleficence has no lunch money; and is always tired. When health worker dealing with the AIDS patients .
79. Which of the following treatment should NOT be D. fidelity and justice the nurse asks the boy his tiredness, he talks of which among these must be done as priority:
considered if the child has severe dengue playing outside until midnight. The nurse will A. Boil used syringe and needles
hemorrhagic fever? 85. Being a community health nurse, you have the suspect that this child is: B. Use gloves when handling specimen
A. use plan C if there is bleeding from the responsibility of participating in protecting the A. Being raised by a parent of low C. Label personal belonging
nose or gums health of people. Consider this situation: intelligence quotient (IQ) D. Avoid accidental wound
B. give ORS if there is skin Petechiae, Vendors selling bread with their bare hands. B. An orphan
persistent vomiting, and positive They receive money with these hands. You do C. A victim of child neglect Situation: Michelle is a 6 year old preschooler. She was
tourniquet test not see them washing their hands. What should D. The victim of poverty reported by her sister to have measles but she is at
C. give aspirin you say/do? home because of fever, upper respiratory problem and
D. prevent low blood sugar A. “Miss, may I get the bread myself 90. Which of the following indicates the type(s) of white sports in her mouth.
because you have not washed your acute renal failure?
80. In assessing the patient’s condition using the hands” A. Four types: hemorrhagic with and 96. Rubeola is an Arabic term meaning Red, the rash
Integrated Management of Childhood Illness B. All of these without clotting, and nonhemorrhagic appears on the skin in invasive stage prior to
approach strategy, the first thing that a nurse C. “Miss, it is better to use a pick up with and without clottings eruption behind the ears. As a nurse, your
should do is to: forceps/ bread tong” B. One type: acute physical examination must determine
D. “Miss, your hands are dirty. Wash your C. Three types: prerenal, intrarenal and complication especially:
A. ask what are the child’s problem hands first before getting the bread” postrenal A. Otitis media
B. check for the four main symptoms D. Two types: acute and subacute B. Inflammatory conjunctiva
C. check the patient’s level of Situation: The following questions refer to common C. Bronchial pneumonia
consciousness clinical encounters experienced by an entry level nurse. Situation: Mike 16 y/o has been diagnosed to have AIDS; D. Membranous laryngitis
D. check for the general danger signs he worked as entertainer in a cruise ship;
86. A female client asks the nurse about the use of a 97. To render comfort measure is one of the
81. A child with diarrhea is observed for the cervical cap. Which statement is correct 91. Which method of transmission is common to priorities, Which includes care of the skin, eyes,
following EXCEPT: regarding the use of the cervical cap? contract AIDS? ears, mouth and nose. To clean the mouth, your
A. how long the child has diarrhea A. It may affect Pap smear results. A. Syringe and needles antiseptic solution is in some form of which one
B. presence of blood in the stool B. It does not need to be fitted by the B. Sexual contact below?
C. skin Petechiae physician. C. Body fluids A. Water
D. signs of dehydration C. It does not require the use of D. Transfusion B. Alkaline
spermicide. C. Sulfur
82. The child with no dehydration needs home D. It must be removed within 24 hours. 92. Causative organism in AIDS is one of the D. Salt
treatment. Which of the following is NOT following;
included in the care for home management at 87. The major components of the communication A. Fungus 98. As a public health nurse, you teach mother and
this case? process are: B. retrovirus family members the prevention of complication
A. give drugs every 4 hours A. Verbal, written and nonverbal C. Bacteria of measles. Which of the following should be
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closely watched? c. 50 days

A. Temperature fails to drop d. 14 days
B. Inflammation of the nasophraynx NURSING PRACTICE III
C. Inflammation of the conjunctiva Situation: As a nurse researcher you must have a very
D. Ulcerative stomatitis Situation: Leo lives in the squatter area. He goes to good understanding of the common terms of concept
nearby school. He helps his mother gather molasses used in research.
99. Source of infection of measles is secretion of after school. One day, he was absent because of fever,
nose and throat of infection person. Filterable malaise, anorexia and abdominal discomfort. 6. The information that an investigator collects
virus of measles is transmitted by: from the subjects or participants in a research
A. Water supply 1. Upon assessment, Leo was diagnosed to have study is usually called;
B. Food ingestion hepatitis A. Which mode of transmission has the a. Hypothesis
C. Droplet infection agent taken? b. Variable
D. Sexual contact a. Fecal-oral c. Data
b. Droplet d. Concept
100. Method of prevention is to avoid c. Airborne
exposure to an infection person. Nursing d. Sexual contact 7. Which of the following usually refers to the
responsibility for rehabilitation of patient independent variables in doing research
includes the provision of: 2. Which of the following is concurrent disinfection a. Result
A. Terminal disinfection in the case of Leo? b. output
B. Immunization a. Investigation of contact c. Cause
C. Injection of gamma globulin b. Sanitary disposal of faeces, urine and d. Effect
D. Comfort measures blood
c. Quarantine of the sick individual 8. The recipients of experimental treatment is an
d. removing all detachable objects in the experimental design or the individuals to be
room, cleaning lighting and air duct observed in a non experimental design are
surfaces in the ceiling, and cleaning called;
everything downward to the floor a. Setting
b. Treatment
3. Which of the following must be emphasized c. Subjects
during mother’s class to Leo’s mother? d. Sample
a. Administration of Immunoglobulin to
families 9. The device or techniques an investigator
b. Thorough hand washing before and employs to collect data is called;
after eating and toileting a. Sample
c. Use of attenuated vaccines b. hypothesis
d. Boiling of food especially meat c. Instrument
d. Concept
4. Disaster control should be undertaken when
there are 3 or more hepatitis A cases. Which of 10. The use of another person’s ideas or wordings
these measures is a priority? without giving appropriate credit results from
a. Eliminate faecal contamination from inaccurate or incomplete attribution of materials
foods to its sources. Which of the following is referred
b. Mass vaccination of uninfected to when another person’s idea is inappropriate
individuals credited as one’s own;
c. Health promotion and education to a. Plagiarism
families and communities about the b. assumption
disease it’s cause and transmission c. Quotation
d. Mass administration of Immunoglobulin d. Paraphrase
5. What is the average incubation period of Situation – Mrs. Pichay is admitted to your ward. The
Hepatitis A? MD ordered “Prepare for thoracentesis this pm to
a. 30 days remove excess air from the pleural cavity.”
b. 60 days
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11. Which of the following nursing responsibilities is a. Ease the patient to the floor common bile duct alleviate anxiety
essential in Mrs. Pichay who will undergo b. Lift the patient and put him on the bed d. The removal of the stones in the kidney c. Avoid overdosing to prevent
thoracentesis? c. Insert a padded tongue depressor dependence/tolerance
a. Support and reassure client during the between his jaws 22. The simplest pain relieving technique is: d. Monitor VS, more importantly RR
procedure d. Restraint patient’s body movement a. Distraction
b. Ensure that informed consent has been b. Deep breathing exercise 28. The client complained of abdominal distention
signed 17. Mr Santos is scheduled for CT SCAN for the next c. Taking aspirin and pain. Your nursing intervention that can
c. Determine if client has allergic reaction day, noon time. Which of the following is the d. Positioning alleviate pain is:
to local anesthesia correct preparation as instructed by the nurse? a. Instruct client to go to sleep and relax
d. Ascertain if chest x-rays and other tests a. Shampoo hair thoroughly to remove oil 23. Which of the following statement on pain is b. Advice the client to close the lips and
have been prescribed and completed and dirt TRUE? avoid deep breathing and talking
b. No special preparation is needed. a. Culture and pain are not associated c. Offer hot and clear soup
12. Mrs. Pichay who is for thoracentesis is assigned Instruct the patient to keep his head b. Pain accompanies acute illness d. Turn to sides frequently and avoid too
by the nurse to which of the following positions? still and stead c. Patient’s reaction to pain Varies much talking
a. Trendelenburg position c. Give a cleansing enema and give fluids d. Pain produces the same reaction such as
b. Supine position until 8 AM groaning and moaning 29. Surgical pain might be minimized by which
c. Dorsal Recumbent position d. Shave scalp and securely attach nursing action in the O.R.
d. Orthopneic position electrodes to it 24. In pain assessment, which of the following a. Skill of surgical team and lesser
condition is a more reliable indicator? manipulation
13. During thoracentesis, which of the following 18. Mr Santos is placed on seizure precaution. a. Pain rating scale of 1 to 10 b. Appropriate preparation for the
nursing intervention will be most crucial? Which of the following would be b. Facial expression and gestures scheduled procedure
a. Place patient in a quiet and cool room contraindicated? c. Physiological responses c. Use of modern technology in closing the
b. Maintain strict aseptic technique a. Obtain his oral temperature d. Patients description of the pain wound
c. Advice patient to sit perfectly still b. Encourage to perform his own personal sensation d. Proper positioning and draping of clients
during needle insertion until it has been hygiene
withdrawn from the chest c. Allow him to wear his own clothing 25. When a client complains of pain, your initial 30. Inadequate anesthesia is said to be one of the
d. Apply pressure over the puncture site as d. Encourage him to be out of bed response is: common cause of pain both in intra and post op
soon as the needle is withdrawn a. Record the description of pain patients. If General anesthesia is desired, it will
19. Usually, how does the patient behave after his b. Verbally acknowledge the pain involve loss of consciousness. Which of the
14. To prevent leakage of fluid in the thoracic cavity, seizure has subsided? c. Refer the complaint to the doctor following are the 2 general types of GA?
how will you position the client after a. Most comfortable walking and moving d. Change to a more comfortable position a. Epidural and Spinal
thoracentesis? about b. Subarachnoid block and Intravenous
a. Place flat in bed b. Becomes restless and agitated Situation: You are assigned at the surgical ward and c. Inhalation and Regional
b. Turn on the unaffected side c. Sleeps for a period of time clients have been complaining of post pain at varying d. Intravenous and Inhalation
c. Turn on the affected side d. Say he is thirsty and hungry degrees. Pain as you know, is very subjective.
d. On bed rest Situation: Nurse’s attitudes toward the pain influence
20. Before, during and after seizure. The nurse 26. A one-day postoperative abdominal surgery the way they perceive and interact with clients in pain.
15. Chest x-ray was ordered after thoracentesis. knows that the patient is ALWAYS placed in what client has been complaining of severe throbbing
When your client asks what is the reason for position? abdominal pain described as 9 in a 1-10 pain 31. Nurses should be aware that older adults are at
another chest x-ray, you will explain: a. Low fowler’s rating. Your assessment reveals bowel sounds on risk of underrated pain. Nursing assessment and
a. To rule out pneumothorax b. Side lying all quadrants and the dressing is dry and intact. management of pain should address the
b. To rule out any possible perforation c. Modified trendelenburg What nursing intervention would you take? following beliefs EXCEPT:
c. To decongest d. Supine a. Medicate client as prescribed a. Older patients seldom tend to report
d. To rule out any foreign body b. Encourage client to do imagery pain than the younger ones
Situation: Mrs. Damian an immediate post op c. Encourage deep breathing and turning b. Pain is a sign of weakness
Situation: A computer analyst, Mr. Ricardo J. Santos, 25 cholecystectomy and choledocholithotomy patient, d. Call surgeon stat c. Older patients do not believe in
was brought to the hospital for diagnostic workup after complained of severe pain at the wound site. analgesics, they are tolerant
he had experienced seizure in his office. 27. Pentoxidone 5 mg IV every 8 hours was d. Complaining of pain will lead to being
21. Choledocholithotomy is: prescribed for post abdominal pain. Which will labeled a ‘bad’ patient
16. Just as the nurse was entering the room, the a. The removal of the gallbladder be your priority nursing action?
patient who was sitting on his chair begins to b. The removal of the stones in the a. Check abdominal dressing for possible 32. Nurses should understand that when a client
have a seizure. Which of the following must the gallbladder swelling responds favorably to a placebo, it is known as
nurse do first? c. The removal of the stones in the b. Explain the proper use of PCA to the ‘placebo effect’. Placebos do not indicate
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whether or not a client has: acting insulin first prepares to initiate which of the following of which of the following physiologic changes
a. Conscience anticipated physician’s order? associated with aging.
b. Disease 37. Janevi complains of nausea, vomiting, a. Endotracheal intubation a. Ineffective airway clearance
c. Real pain diaphoresis and headache. Which of the b. 100 unites of NPH insulin b. Decreased alveolar surfaced area
d. Drug tolerance following nursing intervention are you going to c. Intravenous infusion of normal saline c. Decreased anterior-posterior chest
carry out first? d. Intravenous infusion of sodium diameter
33. You are the nurse in the pain clinic where you a. Withhold the client’s next insulin bicarbonate d. Hyperventilation
have client who has difficulty specifying the injection
location of pain. How can you assist such client? b. Test the client’s blood glucose level 43. Jane eventually developed DKA and is being 47. The older patient is at higher risk for
a. The pain is vague c. Administer Tylenol as ordered treated in the emergency room. Which finding incontinence because of:
b. By charting-it hurts all over d. Offer fruit juice, gelatine and chicken would the nurse expect to note as confirming a. Dilated urethra
c. Identify the absence and presence of bouillon this diagnosis? b. Increased glomerular filtration rate
pain a. Comatose state c. Diuretic use
d. As the client to point to the painful are 38. Janevi administered regular insulin at 7 A.M and b. Decreased urine output d. Decreased bladder capacity
by just one finger the nurse should instruct Jane to avoid c. Increased respiration and an increase in
exercising at around: pH 48. Merle, age 86, is complaining of dizziness when
34. What symptom, more distressing than pain, a. 9 to 11 A.M d. Elevated blood glucose level and low she stands up. This may indicate:
should the nurse monitor when giving opioids b. Between 8 A.M to 9 A.M plasma bicarbonate level a. Dementia
especially among elderly clients who are in pain? c. After 8 hours b. Functional decline
a. Forgetfulness d. In the afternoon, after taking lunch 44. The nurse teaches Jane to know the difference c. A visual problem
b. Drowsiness between hypoglycaemia and ketoacidosis. Jane d. Drug toxicity
c. Constipation 39. Janevi was brought at the emergency room after demonstrates understanding of the teaching by
d. Allergic reactions like pruritis four month because she fainted in her clinic. The stating that glucose will be taken if which of the 49. Cardiac ischemia in an older patient usually
nurse should monitor which of the following test following symptoms develops? produces:
35. Physical dependence occurs in anyone who to evaluate the overall therapeutic compliance a. Polyuria a. ST-T wave changes
takes opiods over a period of time. What do you of a diabetic patient? b. Shakiness b. Chest pain radiating to the left arm
tell a mother of a ‘dependent’ when asked for a. Glycosylated hemoglobin c. Blurred Vision c. Very high creatinine kinase level
advice? b. Ketone levels d. Fruity breath odour d. Acute confusion
a. Start another drug and slowly lessen the c. Fasting blood glucose
opioid dosage d. Urine glucose level 45. Jane has been scheduled to have a FBS taken in 50. The most dependable sign of infection in the
b. Indulge in recreational outdoor activities the morning. The nurse tells Jane not to eat or older patient is:
c. Isolate opioid dependent to a restful 40. Upon the assessment of Hba1c of Mrs. Segovia, drink after midnight. Prior to taking the blood a. Change in mental status
resort The nurse has been informed of a 9% Hba1c specimen, the nurse noticed that Jane is holding b. Fever
d. Instruct slow tapering of the drug result. In this case, she will teach the patient to: a bottle of distilled water. The nurse asked Jane c. Pain
dosage and alleviate physical a. Avoid infection if she drink any, and she said “yes.” Which of the d. Decreased breath sounds with crackles
withdrawal symptoms b. Prevent and recognize hyperglycaemia following is the best nursing action?
c. Take adequate food and nutrition a. Administer syrup of ipecac to remove Situation – In the OR, there are safety protocols that
Situation: The nurse is performing health education d. Prevent and recognize hypoglycaemia the distilled water from the stomach should be followed. The OR nurse should be well versed
activities for Janevi Segovia, a 30 year old Dentist with b. Suction the stomach content using NGT with all these to safeguard the safety and quality of
Insulin dependent diabetes Miletus. 41. The nurse is teaching plan of care for Jane with prior to specimen collection patient delivery outcome.
regards to proper foot care. Which of the c. Advice to physician to reschedule to
36. Janevi is preparing a mixed dose of insulin. The following should be included in the plan? diagnostic examination next day 51. Which of the following should be given highest
nurse is satisfied with her performance when a. Soak feet in hot water d. Continue as usual and have the FBS priority when receiving patient in the OR?
she: b. Avoid using mild soap on the feet analysis performed and specimen be a. Assess level of consciousness
a. Draw insulin from the vial of clear c. Apply a moisturizing lotion to dry feet taken b. Verify patient identification and
insulin first but not between the toes informed consent
b. Draw insulin from the vial of the d. Always have a podiatrist to cut your toe Situation: Elderly clients usually produce unusual signs c. Assess vital signs
intermediate acting insulin first nails; never cut them yourself when it comes to different diseases. The ageing process d. Check for jewelry, gown, manicure, and
c. Fill both syringes with the prescribed is a complicated process and the nurse should dentures
insulin dosage then shake the bottle 42. Another patient was brought to the emergency understand that it is an inevitable fact and she must be
vigorously room in an unresponsive state and a diagnosis of prepared to care for the growing elderly population. 52. Surgeries like I and D (incision and drainage) and
d. Withdraw the intermediate acting hyperglycaemic hyperosmolar nonketotic debridement are relatively short procedures but
insulin first before withdrawing the short syndrome is made. The nurse immediately 46. Hypoxia may occur in the older patients because considered ‘dirty cases’. When are these
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procedures best scheduled? The nurse knows that the temperature and time 62. As a perioperative nurse, how can you best meet patients will need surgical amputation but there
a. Last case is set to the optimum level to destroy not only the safety need of the client after administering are no sterile surgical equipments. In this case,
b. In between cases the microorganism, but also the spores. Which preoperative narcotic? which of the following will the nurse expect?
c. According to availability of of the following is the ideal setting of the a. Put side rails up and ask the client not a. Equipments needed for surgery need not
anaesthesiologist autoclave machine? to get out of bed be sterilized if this is an emergency
d. According to the surgeon’s preference a. 10,000 degree Celsius for 1 hour b. Send the client to OR with the family necessitating life saving measures
b. 5,000 degree Celsius for 30 minutes c. Allow client to get up to go to the b. Forwarding the trauma client to the
53. OR nurses should be aware that maintaining the c. 37 degree Celsius for 15 minutes comfort room nearest hospital that has available sterile
client’s safety is the overall goal of nursing care d. 121 degree Celsius for 15 minutes d. Obtain consent form equipments is appropriate
during the intraoperative phase. As the c. The nurse will need to sterilize the item
circulating nurse, you make certain that 58. It is important that before a nurse prepares the 63. It is the responsibility of the pre-op nurse to do before using it to the client using the
throughout the procedure… material to be sterilized, a chemical indicator skin prep for patients undergoing surgery. If hair regular sterilization setting at 121
a. the surgeon greets his client before strip should be placed above the package, at the operative site is not shaved, what should degree Celsius in 15 minutes
induction of anesthesia preferably, Muslin sheet. What is the color of be done to make suturing easy and lessen d. In such cases, flash sterlizer will be use
b. the surgeon and anesthesiologist are in the striped produced after autoclaving? chance of incision infection? at 132 degree Celsius in 3 minutes
tandem a. Black a. Draped
c. strap made of strong non-abrasive b. Blue b. Pulled 68. Tess, the PACU nurse, discovered that Malou,
materials are fastened securely around c. Gray c. Clipped who weighs 110 lbs prior to surgery, is in severe
the joints of the knees and ankles and d. Purple d. Shampooed pain 3 hrs after cholecystectomy. Upon checking
around the 2 hands around an arm the chart, Malou found out that she has an order
board. 59. Chemical indicators communicate that: 64. It is also the nurse’s function to determine when of Demerol 100 mg I.M. prn for pain. Tess should
d. Client is monitored throughout the a. The items are sterile infection is developing in the surgical incision. verify the order with:
surgery by the assistant anesthesiologist b. That the items had undergone The perioperative nurse should observe for what a. Nurse Supervisor
sterilization process but not necessarily signs of impending infection? b. Surgeon
54. Another nursing check that should not be missed sterile a. Localized heat and redness c. Anesthesiologist
before the induction of general anesthesia is: c. The items are disinfected b. Serosanguinous exudates and skin d. Intern on duty
a. check for presence underwear d. That the items had undergone blanching
b. check for presence dentures disinfection process but not necessarily c. Separation of the incision 69. Rosie, 57, who is diabetic is for debridement if
c. check patient’s ID disinfected d. Blood clots and scar tissue are visible incision wound. When the circulating nurse
d. check baseline vital signs checked the present IV fluid, she found out that
60. If a nurse will sterilize a heat and moisture labile 65. Which of the following nursing interventions is there is no insulin incorporated as ordered.
55. Some lifetime habits and hobbies affect instruments, It is according to AORN done when examining the incision wound and What should the circulating nurse do?
postoperative respiratory function. If your client recommendation to use which of the following changing the dressing? a. Double check the doctor’s order and
smokes 3 packs of cigarettes a day for the past method of sterilization? a. Observe the dressing and type and odor call the attending MD
10 years, you will anticipate increased risk for: a. Ethylene oxide gas of drainage if any b. Communicate with the ward nurse to
a. perioperative anxiety and stress b. Autoclaving b. Get patient’s consent verify if insulin was incorporated or not
b. delayed coagulation time c. Flash sterilizer c. Wash hands c. Communicate with the client to verify if
c. delayed wound healing d. Alcohol immersion d. Request the client to expose the incision insulin was incorporated
d. postoperative respiratory infection wound d. Incorporate insulin as ordered.
Situation 5 – Nurses hold a variety of roles when
Situation: Sterilization is the process of removing ALL providing care to a perioperative patient. Situation – The preoperative nurse collaborates with the 70. The documentation of all nursing activities
living microorganism. To be free of ALL living client significant others, and healthcare providers. performed is legally and professionally vital.
microorganism is sterility. 61. Which of the following role would be the Which of the following should NOT be included
responsibility of the scrub nurse? 66. To control environmental hazards in the OR, the in the patient’s chart?
56. There are 3 general types of sterilization use in a. Assess the readiness of the client prior nurse collaborates with the following a. Presence of prosthetoid devices such as
the hospital, which one is not included? to surgery departments EXCEPT: dentures, artificial limbs hearing aid, etc.
a. Steam sterilization b. Ensure that the airway is adequate a. Biomedical division b. Baseline physical, emotional, and
b. Physical sterilization c. Account for the number of sponges, b. Infection control committee psychosocial data
c. Chemical sterilization needles, supplies, used during the c. Chaplaincy services c. Arguments between nurses and
d. Sterilization by boiling surgical procedure. d. Pathology department residents regarding treatments
d. Evaluate the type of anesthesia d. Observed untoward signs and symptoms
57. Autoclave or steam under pressure is the most appropriate for the surgical client 67. An air crash occurred near the hospital leading and interventions including contaminant
common method of sterilization in the hospital. to a surge of trauma patient. One of the last intervening factors
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Situation: Basic knowledge on Intravenous solutions is order?

Situation – Team efforts is best demonstrated in the OR. necessary for care of clients with problems with fluids a. Any IV solution available to KVO 86. As an OR nurse, what are your foremost
and electrolytes. b. Isotonic solution considerations for selecting chemical agents for
71. If you are the nurse in charge for scheduling c. Hypertonic solution disinfection?
surgical cases, what important information do 76. A client involved in a motor vehicle crash d. Hypotonic solution a. Material compatibility and efficiency
you need to ask the surgeon? presents to the emergency department with b. Odor and availability
a. Who is your internist severe internal bleeding. The client is severely 81. An informed consent is required for: c. Cost and duration of disinfection process
b. Who is your assistant and hypotensive and unresponsive. The nurse a. closed reduction of a fracture d. Duration of disinfection and efficiency
anaesthesiologist, and what is your anticipates which of the following intravenous b. irrigation of the external ear canal
preferred time and type of surgery? solutions will most likely be prescribed to c. insertion of intravenous catheter 87. Before you use a disinfected instrument it is
c. Who are your anaesthesiologist, increase intravascular volume, replace d. urethral catheterization essential that you:
internist, and assistant immediate blood loss and increase blood a. Rinse with tap water followed by alcohol
d. Who is your anaesthesiologist pressure? 82. Which of the following is not true with regards b. Wrap the instrument with sterile water
a. 0.45% sodium chloride to the informed consent? c. Dry the instrument thoroughly
72. In the OR, the nursing tandem for every surgery b. 0.33% sodium chloride a. It should describe different treatment d. Rinse with sterile water
is: c. Normal saline solution alternatives
a. Instrument technician and circulating d. Lactated ringer’s solution b. It should contain a thorough and 88. You have a critical heat labile instrument to
nurse detailed explanation of the procedure sterilize and are considering to use high level
b. Nurse anaesthetist, nurse assistant, and 77. The physician orders the nurse to prepare an to be done disinfectant. What should you do?
instrument technician isotonic solution. Which of the following IV c. It should describe the client’s diagnosis a. Cover the soaking vessel to contain the
c. Scrub nurse and nurse anaesthetist solution would the nurse expect the intern to d. It should give an explanation of the vapor
d. Scrub and circulating nurses prescribe? client’s prognosis b. Double the amount of high level
a. 5% dextrose in water disinfectant
73. While team effort is needed in the OR for b. 0.45% sodium chloride 83. You know that the hallmark of nursing c. Test the potency of the high level
efficient and quality patient care delivery, we c. 10% dextrose in water accountability is the: disinfectant
should limit the number of people in the room d. 5% dextrose in 0.9% sodium chloride a. accurate documentation and reporting d. Prolong the exposure time according to
for infection control. Who comprise this team? b. admitting your mistakes manufacturer’s direction
a. Surgeon, anaesthesiologist, scrub nurse, 78. The nurse is making initial rounds on the nursing c. filing an incidence report
radiologist, orderly unit to assess the condition of assigned clients. d. reporting a medication error 89. To achieve sterilization using disinfectants,
b. Surgeon, assistants, scrub nurse, The nurse notes that the client’s IV Site is cool, which of the following is used?
circulating nurse, anaesthesiologist pale and swollen and the solution is not infusing. 84. A nurse is assigned to care for a group of clients. a. Low level disinfectants immersion in 24
c. Surgeon, assistant surgeon, The nurse concludes that which of the following On review of the client’s medical records, the hours
anaesthesiologist, scrub nurse, complications has been experienced by the nurse determines that which client is at risk for b. Intermediate level disinfectants
pathologist client? excess fluid volume? immersion in 12 hours
d. Surgeon, assistant surgeon, a. Infection a. The client taking diuretics c. High level disinfectants immersion in 1
anaesthesiologist, intern, scrub nurse b. Phlebitis b. The client with renal failure hour
c. Infiltration c. The client with an ileostomy d. High level disinfectant immersion in 10
74. Who usually act as an important part of the OR d. Thrombophelibitis d. The client who requires gastrointestinal hours
personnel by getting the wheelchair or stretcher, suctioning
and pushing/pulling them towards the operating 79. A nurse reviews the client’s electrolyte 90. Bronchoscope, Thermometer, Endoscope, ET
room? laboratory report and notes that the potassium 85. A nurse is assigned to care for a group of clients. tube, Cytoscope are all BEST sterilized using
a. Orderly/clerk level is 3.2 mEq/L. Which of the following would On review of the client’s medical records, the which of the following?
b. Nurse Supervisor the nurse note on the electrocardiogram as a nurse determines that which client is at risk for a. Autoclaving at 121 degree Celsius in 15
c. Circulating Nurse result of the laboratory value? deficient fluid volume? minutes
d. Anaesthesiologist a. U waves a. A client with colostomy b. Flash sterilizer at 132 degree Celsius in 3
b. Absend P waves b. A client with congestive heart failure minutes
75. The breakdown in teamwork is often times a c. Elevated T waves c. A client with decreased kidney function c. Ethylene Oxide gas aeration for 20 hours
failure in: d. Elevated ST segment d. A client receiving frequent wound d. 2% Glutaraldehyde immersion for 10
a. Electricity irrigation hours
b. Inadequate supply 80. One patient had a ‘runaway’ IV of 50% dextrose.
c. Leg work To prevent temporary excess of insulin or Situation: As a perioperative nurse, you are aware of the Situation: The OR is divided into three zones to control
d. Communication transient hyperinsulin reaction what solution correct processing methods for preparing instruments traffic flow and contamination
you prepare in anticipation of the doctor’s and other devices for patient use to prevent infection.
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91. What OR attires are worn in the restricted area? process d. CT Scan and Incidence report
a. Scrub suit, OR shoes, head cap
b. Head cap, scrub suit, mask, OR shoes 97. 2 organizations endorsed that sterility are NURSING PRACTICE IV Situation: An entry level nurse should be able to apply
c. Mask, OR shoes, scrub suit affected by factors other than the time itself, theoretical knowledge in the performance of the basic
d. Cap, mask, gloves, shoes these are: Situation: After an abdominal surgery, the circulating nursing skills.
a. The PNA and the PRC and scrub nurses have critical responsibility about
92. Nursing intervention for a patient on low dose IV b. AORN and JCAHO sponge and instrument count. 6. A client has an indwelling urinary catheter and
insulin therapy includes the following, EXCEPT: c. ORNAP and MCNAP she is suspected of having urinary infection. How
a. Elevation of serum ketones to monitor d. MMDA and DILG 1. Counting is performed thrice: During the should you collect a urine specimen for culture
ketosis preincision phase, the operative phase and and sensitivity?
b. Vital signs including BP 98. All of these factors affect the sterility of the OR closing phase. Who counts the sponges, needles a. clamp tubing for 60 minutes and insert a
c. Estimate serum potassium equipments, these are the following except: and instruments? sterile needle into the tubing above the
d. Elevation of blood glucose levels a. The material used for packaging a. The scrub nurse only clamp to aspirate urine
b. The handling of the materials as well as b. The circulating nurse only b. drain urine from the drainage bag into
93. The doctor ordered to incorporate 1000”u” its transport c. The surgeon and the assistant surgeon the sterile container
insulin to the remaining on-going IV. The c. Storage d. The scrub nurse and the circulating c. disconnect the tubing from the urinary
strength is 500 /ml. How much should you d. The chemical or process used in nurse catheter and let urine flow into a sterile
incorporate into the IV solution? sterililzing the material container
a. 10 ml 2. The layer of the abdomen is divided into 5. d. wipe the self-sealing aspiration port
b. 0.5 ml 99. When you say sterile, it means: Arrange the following from the first layer going with antiseptic solution and insert a
c. 2 ml a. The material is clean to the deepest layer: sterile needle into the self-sealing port
d. 5 ml b. The material as well as the equipments 1. Fascia
are sterilized and had undergone a 2. Muscle 7. To obtain specimen for sputum culture and
94. Multiple vial-dose-insulin when in use should be rigorous sterilization process 3. Peritoneum sensitivity, which of the following instruction is
a. Kept at room temperature c. There is a black stripe on the paper 4. Subcutaneous/Fat best?
b. Kept in narcotic cabinet indicator 5. Skin a. Upon waking up, cough deeply and
c. Kept in the refrigerator d. The material has no microorganism nor a. 5,4,3,2,1 expectorate into container
d. Store in the freezer spores present that might cause an b. 5,4,1,3,2 b. Cough after pursed lip breathing
infection c. 5,4,2,1,3 c. Save sputum for two days in covered
95. Insulins using insulin syringe are given using how d. 5,4,1,2,3 container
many degrees of needle insertion? 100. In using liquid sterilizer versus autoclave d. After respiratory treatment, expectorate
a. 45 machine, which of the following is true? 3. When is the first sponge/instrument count into a container
b. 180 a. Autoclave is better in sterilizing OR reported?
c. 90 supplies versus liquid sterilizer a. Before closing the subcutaneous layer 8. The best time for collecting the sputum
d. 15 b. They are both capable of sterilizing the b. Before peritoneum is closed specimen for culture and sensitivity is:
equipments, however, it is necessary to c. Before closing the skin a. Before retiring at night
Situation: Maintenance of sterility is an important soak supplies in the liquid sterilizer for d. Before the fascia is sutured b. Anytime of the day
function a nurse should perform in any OR setting. a longer period of time c. Upon waking up in the morning
c. Sharps are sterilized using autoclave and 4. Like any nursing interventions, counts should be d. Before meals
96. Which of the following is true with regards to not cidex documented. To whom does the scrub nurse
sterility? d. If liquid sterilizer is used, rinsing it report any discrepancy of counts so that 9. When suctioning the endotracheal tube, the
a. Sterility is time related, items are not before using is not necessary immediate and appropriate action is instituted? nurse should:
considered sterile after a period of 30 a. Anaesthesiologists a. Explain procedure to patient; insert
days of being not use. b. Surgeon catheter gently applying suction.
b. for 9 months, sterile items are c. OR nurse supervisor Withdrawn using twisting motion
considered sterile as long as they are d. Circulating nurse b. Insert catheter until resistance is met,
covered with sterile muslin cover and and then withdraw slightly, applying
stored in a dust proof covers. 5. Which of the following are 2 interventions of the suction intermittently as catheter is
c. Sterility is event related, not time surgical team when an instrument was withdrawn
related confirmed missing? c. Hyperoxygenate client insert catheter
d. For 3 weeks, items double covered with a. MRI and Incidence report using back and forth motion
muslin are considered sterile as long as b. CT Scan, MRI, Incidence report d. Insert suction catheter four inches into
they have undergone the sterilization c. X-RAY and Incidence report the tube, suction 30 seconds using
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twirling motion as catheter is withdrawn Nursing intervention includes: assessment findings and interventions are d. Fever, Irritability and a large output of
a. Bed rest important responsibilities of the nurse during diluted urine
10. The purpose of NGT IMMEDIATELY after an b. Warm moist soak first post-operative day, which of the following is
operation is: c. Early ambulation the LEAST relevant to document in the case of 25. What kind of renal failure will melamine
a. For feeding or gavage d. Hot sitz bath Mang Felix? poisoning cause?
b. For gastric decompression a. Chest pain and vital signs a. Chronic, Prerenal
c. For lavage, or the cleansing of the Situation – Mang Felix, a 79 year old man who is brought b. Intravenous infusion rate b. Chronic, Intrarenal
stomach content to the Surgical Unit from PACU after a transurethral c. Amount, color, and consistency of c. Acute, Postrenal
d. For the rapid return of peristalsis resection. You are assigned to receive him. You noted bladder irrigation drainage d. Acute, Prerenal
that he has a 3-way indwelling urinary catheter for d. Activities of daily living started
Situation - Mr. Santos, 50, is to undergo cystoscopy due continuous fast drip bladder irrigation which is Situation: Leukemia is the most common type of
to multiple problems like scantly urination, hematuria connected to a straight drainage. Situation: Melamine contamination in milk has brought childhood cancer. Acute Lymphoid Leukemia is the cause
and dysuria. worldwide crisis both in the milk production sector as of almost 1/3 of all cancer that occurs in children under
16. Immediately after surgery, what would you well as the health and economy. Being aware of the age 15.
11. You are the nurse in charge in Mr. Santos. When expect his urine to be? current events is one quality that a nurse should possess
asked what are the organs to be examined a. Light yellow to prove that nursing is a dynamic profession that will 26. The survival rate for Acute Lymphoid Leukemia is
during cystoscopy, you will enumerate as b. Bright red adapt depending on the patient’s needs. approximately:
follows: c. Amber a. 25%
a. Urethra, kidney, bladder, urethra d. Pinkish to red 21. Melamine is a synthetic resin used for b. 40%
b. Urethra, bladder wall, trigone, ureteral whiteboards, hard plastics and jewellery box c. 75%
opening 17. The purpose of the continuous bladder irrigation covers due to its fire retardant properties. Milk d. 95%
c. Bladder wall, uterine wall, and urethral is to: and food manufacturers add melamine in order
opening a. Allow continuous monitoring of the fluid to: 27. Whereas acute nonlymphoid leukemia has a
d. Urethral opening, ureteral opening output status a. It has a bacteriostatic property leading survival rate of:
bladder b. Provide continuous flushing of clots and to increase food and milk life as a way of a. 25%
debris from the bladder preserving the foods b. 40%
12. In the OR, you will position Mr. Santos who is c. Allow for proper exchange of b. Gives a glazy and more edible look on c. 75%
cystoscopy in: electrolytes and fluid foods d. 95%
a. Supine d. Ensure accurate monitoring of intake c. Make milks more tasty and creamy
b. Lithotomy and output d. Create an illusion of a high protein 28. The three main consequence of leukemia that
c. Semi-fowler content on their products cause the most danger is:
d. Trendelenburg 18. Mang Felix informs you that he feels some a. Neutropenia causing infection, anemia
discomfort on the hypogastric area and he has to 22. Most of the milks contaminated by Melamine causing impaired oxygenation and
13. After cystoscopy, Mr. Santos asked you to void. What will be your most appropriate action? came from which country? thrombocytopenia leading to bleeding
explain why there is no incision of any kind. a. Remove his catheter then allow him to a. India tendencies
What do you tell him? void on his own b. China b. Central nervous system infiltration,
a. “Cystoscopy is direct visualization and b. Irrigate his catheter c. Philippines anemia causing impaired oxygenation
examination by urologist”. c. Tell him to “Go ahead and void. You d. Korea and thrombocytopenia leading to
b. “Cystoscopy is done by x-ray have an indwelling catheter.” bleeding tendencies
visualization of the urinary tract”. d. Assess color and rate of outflow, if 23. Which government agency is responsible for c. Splenomegaly, hepatomegaly, fractures
c. “Cystoscopy is done by using lasers on there is changes refer to urologist for testing the melamine content of foods and food d. Invasion by the leukemic cells to the
the urinary tract”. possible irrigation. products? bone causing severe bone pain
d. “Cystoscopy is an endoscopic procedure a. DOH
of the urinary tract”. 19. You decided to check on Mang Felix’s IV fluid b. MMDA 29. Gold standard in the diagnosis of leukemia is by
infusion. You noted a change in flow rate, pallor c. NBI which of the following?
14. Within 24-48 hours post cystoscopy, it is normal and coldness around the insertion site. What is d. BFAD a. Blood culture and sensitivity
to observe one the following: your assessment finding? b. Bone marrow biopsy
a. Pink-tinged urine a. Phlebitis 24. Infants are the most vulnerable to melamine c. Blood biopsy
b. Distended bladder b. Infiltration to subcutaneous tissue poisoning. Which of the following is NOT a sign d. CSF aspiration and examination
c. Signs of infection c. Pyrogenic reaction of melamine poisoning?
d. Prolonged hematuria d. Air embolism a. Irritability, Back ache, Urolithiasis 30. Adriamycin,Vincristine,Prednisone and L
b. High blood pressure, fever asparaginase are given to the client for long
15. Leg cramps are NOT uncommon post cystoscopy. 20. Knowing that proper documentation of c. Anuria, Oliguria or Hematuria term therapy. One common side effect,
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especially of adriamycin is alopecia. The child sensitivity of the breast. b. lumps in the breast tissue d. Ineffective tissue perfusion, peripheral,
asks: “Will I get my hair back once again?” The c. axillary lymphnodes cerebral, cardiovascular,
nurse best respond is by saying: 34. Carmen, who is asking the nurse the most d. change in size and contour gastrointestinal, renal
a. “Don’t be silly, ofcourse you will get your appropriate time of the month to do her self-
hair back” examination of the breast. The MOST 40. When preparing to examine the left breast in a 45. What intervention should you include in your
b. “We are not sure, let’s hope it’ll grow” appropriate reply by the nurse would be: reclining position, the purpose of placing a small care plan?
c. “This side effect is usually permanent, a. the 26th day of the menstrual cycle folded towel under the client’s left shoulder is a. Inspect his skin for petechiae, bruising,
But I will get the doctor to discuss it for b. 7 to 8 days after conclusion of the to: GI bleeding regularly
you” menstrual period a. bring the breast closer to the examiner’s b. Place Albert on strict isolation
d. “Your hair will regrow in 3 to 6 months c. during her menstruation right hand precaution
but of different color, usually darker d. the same day each month b. tense the pectoral muscle c. Provide rest in between activities
and of different texture” c. balance the breast tissue more evenly d. Administer antipyretics if his
35. Carmen being treated with radiation therapy. on the chest wall temperature exceeds 38C
Situation: Breast Cancer is the 2nd most common type of What should be included in the plan of care to d. facilitate lateral positioning of the breast
cancer after lung cancer and 99% of which, occurs in minimize skin damage from the radiation Situation: Burn are cause by transfer of heat source to
woman. Survival rate is 98% if this is detected early and therapy? Situation – Radiation therapy is another modality of the body. It can be thermal, electrical, radiation or
treated promptly. Carmen is a 53 year old patient in the a. Cover the areas with thick clothing cancer management. With emphasis on multidisciplinary chemical.
high risk group for breast cancer was recently diagnosed materials management you have important responsibilities as
with Breast cancer. b. Apply a heating pad to the site nurse. 46. A burn characterized by Pale white appearance,
c. Wash skin with water after the therapy charred or with fat exposed and painlessness is:
31. All of the following are factors that said to d. Avoid applying creams and powders to 41. Albert is receiving external radiation therapy and a. Superficial partial thickness burn
contribute to the development of breast cancer the area he complains of fatigue and malaise. Which of b. Deep partial thickness burn
except: the following nursing interventions would be c. Full thickness burn
a. Prolonged exposure to estrogen such as 36. Based on the DOH and World Health most helpful for Albert? d. Deep full thickness burn
an early menarche or late menopause, Organization (WHO) guidelines, the mainstay for a. Tell him that sometimes these feelings
nulliparity and childbirth after age 30 early detection method for breast cancer that is can be psychogenic 47. Which of the following BEST describes superficial
b. Genetics recommended for developing countries is: b. Refer him to the physician partial thickness burn or first degree burn?
c. Increasing Age a. a monthly breast self-examination (BSE) c. Reassure him that these feelings are a. Structures beneath the skin are damage
d. Prolonged intake of Tamoxifen and an annual health worker breast normal b. Dermis is partially damaged
(Nolvadex) examination (HWBE) d. Help him plan his activities c. Epidermis and dermis are both damaged
b. an annual hormone receptor assay d. Epidermis is damaged
32. Protective factors for the development of breast c. an annual mammogram 42. Immediately following the radiation teletherapy,
cancer includes which of the following except: d. a physician conduct a breast clinical Albert is 48. A burn that is said to be “WEEPING” is classified
a. Exercise examination every 2 years a. Considered radioactive for 24 hrs as:
b. Breast feeding b. Given a complete bath a. Superficial partial thickness burn
c. Prophylactic Tamoxifen 37. The purpose of performing the breast self- c. Placed on isolation for 6 hours b. Deep partial thickness burn
d. Alcohol intake examination (BSE) regularly is to discover: d. Free from radiation c. Full thickness burn
a. fibrocystic masses d. Deep full thickness burn
33. A patient diagnosed with breast cancer has been b. areas of thickness or fullness 43. Albert is admitted with a radiation induced
offered the treatment choices of breast c. cancerous lumps thrombocytopenia. As a nurse you should 49. During the Acute phase of the burn injury, which
conservation surgery with radiation or a d. changes from previous BSE observe the following symptoms: of the following is a priority?
modified radical mastectomy. When questioned a. Petechiae, ecchymosis, epistaxis a. wound healing
by the patient about these options, the nurse 38. If you are to instruct a postmenopausal woman b. Weakness, easy fatigability, pallor b. emotional support
informs the patient that the lumpectomy with about BSE, when would you tell her to do BSE: c. Headache, dizziness, blurred vision c. reconstructive surgery
radiation: a. on the same day of each month d. Severe sore throat, bacteremia, d. fluid resuscitation
a. reduces the fear and anxiety that b. on the first day of her menstruation hepatomegaly
accompany the diagnosis and treatment c. right after the menstrual period 50. While in the emergent phase, the nurse knows
of cancer d. on the last day of her menstruation 44. What nursing diagnosis should be of highest that the priority is to:
b. has about the same 10-year survival rate priority? a. Prevent infection
as the modified radical mastectomy 39. During breast self-examination, the purpose of a. Knowledge deficit regarding b. Prevent deformities and contractures
c. provides a shorter treatment period with standing in front of the mirror it to observe the thrombocytopenia precautions c. Control pain
a fewer long term complications breast for: b. Activity intolerance d. Return the hemodynamic stability via
d. preserves the normal appearance and a. thickening of the tissue c. Impaired tissue integrity fluid resuscitation
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the client is developing: contamination is no longer a danger it is important for nurses to gather as much information
51. The MOST effective method of delivering pain a. Cerebral hypoxia d. The stools starts to become formed, to be able to address their needs for nursing care.
medication during the emergent phase is: b. metabolic acidosis around the 7th postoperative day
a. intramuscularly c. Hypervolemia 66. Critically ill patients frequently complain about
b. orally d. Renal failure 62. When preparing to teach Fermin how to irrigate which of the following when hospitalized?
c. subcutaneously colostomy, you should plan to do the procedure: a. Hospital food
d. intravenously 58. A 165 lbs trauma client was rushed to the a. When Fermin would have normal bowel b. Lack of privacy
emergency room with full thickness burns on the movement c. Lack of blankets
52. When a client accidentally splashes chemicals to whole face, right and left arm, and at the b. At least 2 hours before visiting hours d. Inadequate nursing staff
his eyes, The initial priority care following the anterior upper chest sparing the abdominal area. c. Prior to breakfast and morning care
chemical burn is to: He also has superficial partial thickness burn at d. After Fermin accepts alteration in body 67. Who of the following is at greatest risk of
a. irrigate with normal saline for 1 to 15 the posterior trunk and at the half upper portion image developing sensory problem?
minutes of the left leg. He is at the emergent phase of a. Female patient
b. transport to a physician immediately burn. Using the parkland’s formula, you know 63. When observing a return demonstration of a b. Transplant patient
c. irrigate with water for 15 minutes or that during the first 8 hours of burn, the amount colostomy irrigation, you know that more c. Adoloscent
longer of fluid will be given is: teaching is required if Fermin: d. Unresponsive patient
d. cover the eyes with a sterile gauze a. 5,400 ml a. Lubricates the tip of the catheter prior to
b. 9, 450 ml inserting into the stoma 68. Which of the following factors may inhibit
53. Which of the following can be a fatal c. 10,800 ml b. Hangs the irrigating bag on the learning in critically ill patients?
complication of upper airway burns? d. 6,750 ml bathroom door cloth hook during fluid a. Gender
a. stress ulcers insertion b. Educational level
b. shock 59. The doctor incorporated insulin on the client’s c. Discontinues the insertion of fluid after c. Medication
c. hemorrhage fluid during the emergent phase. The nurse 500 ml of fluid has been instilled d. Previous knowledge of illness
d. laryngeal spasms and swelling knows that insulin is given because: d. Clamps of the flow of fluid when felling
a. Clients with burn also develops uncomfortable 69. Which of the following statements does not
54. When a client will rush towards you and he has a Metabolic acidosis apply to critically ill patients?
burning clothes on, It is your priority to do which b. Clients with burn also develops 64. You are aware that teaching about colostomy a. Majority need extensive rehabilitation
of the following first? hyperglycemia care is understood when Fermin states, “I will b. All have been hospitalized previously
a. log roll on the grass/ground c. Insulin is needed for additional energy contact my physician and report: c. Are physically unstable
b. slap the flames with his hands and glucose burning after the stressful a. If I have any difficulty inserting the d. Most have chronic illness
c. Try to remove the burning clothes incidence to hasten wound healing, irrigating tub into the stoma.”
d. Splash the client with 1 bucket of cool regain of consciousness and rapid return b. If I noticed a loss of sensation to touch in 70. Families of critically ill patients desire which of
water of hemodynamic stability the stoma tissue.” the following needs to be met first by the nurse?
d. For hyperkalemia c. The expulsion of flatus while the a. Provision of comfortable space
55. Once the flames are extinguished, it is most irrigating fluid is running out.” b. Emotional support
important to: 60. The IV fluid of choice for burn as well as d. When mucus is passed from the stoma c. Updated information on client’s status
a. cover clientwith a warm blanket dehydration is: between the irrigations.” d. Spiritual counselling
b. give him sips of water a. 0.45% NaCl
c. calculate the extent of his burns b. Sterile water 65. You would know after teaching Fermin that Situation: Johnny, sought consultation to the hospital
d. assess the Sergio’s breathing c. NSS dietary instruction for him is effective when he because of fatigability, irritability, jittery and he has been
d. D5LR states, “It is important that I eat: experiencing this sign and symptoms for the past 5
56. During the first 24 hours after the thermal injury, a. Soft food that is easily digested and months.
you should asses Sergio for: Situation: ENTEROSTOMAL THERAPY is now considered a absorbed by my large intestines.”
a. hypokalemia and hypernatremia specialty in nursing. You are participating in the OSTOMY b. Bland food so that my intestines do not 71. His diagnosis was hyperthyroidism, the following
b. hypokalemia and hyponatremia CARE CLASS. become irritated.” are expected symptoms except:
c. hyperkalemia and hyponatremia c. Food low in fiber so that there are fewer a. Anorexia
d. hyperkalemia and hypernatremia 61. You plan to teach Fermin how to irrigate the stools.” b. Fine tremors of the hand
colostomy when: d. Everything that I ate before the c. Palpitation
57. A client who sustained deep partial thickness a. The perineal wound heals And Fermin operation, while avoiding foods that d. Hyper alertness
and full thickness burns of the face, whole can sit comfortably on the commode cause gas”.
anterior chest and both upper extremities two b. Fermin can lie on the side comfortably, 72. She has to take drugs to treat her
days ago begins to exhibit extreme restlessness. about the 3rd postoperative day Situation: Based on studies of nurses working in special hyperthyroidism. Which of the following will you
You recognize that this most likely indicates that c. The abdominal incision is closed and units like the intensive care unit and coronary care unit, NOT expect that the doctor will prescribe?
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a. Colace (Docusate) to: d. Cleaning d. Tetany

b. Tapazole (Methimazole) a. Decrease the vascularity and size of the
c. Cytomel (Liothyronine) thyroid gland 84. While critical items and should be: 90. After surgery Johnny develops peripheral
d. Synthroid (Levothyroxine) b. Decrease the size of the thyroid gland a. Clean numbness, tingling and muscle twitching and
only b. Sterilized spasm. What would you anticipate to
73. The nurse knows that Tapazole has which of the c. Increase the vascularity and size of the c. Decontaminated administer?
following side effect that will warrant immediate thyroid gland d. Disinfected a. Magnesium sulfate
withholding of the medication? d. Increase the size of the thyroid gland b. Potassium iodide
a. Death only 85. As a nurse, you know that intact skin acts as an c. Calcium gluconate
b. Hyperthermia effective barrier to most microorganisms. d. Potassium chloride
c. Sore throat 79. Which of the following is a side effect of Lugol’s Therefore, items that come in contact with the
d. Thrombocytosis solution? intact skin or mucus membranes should be: Situation: Budgeting is an important part of a nurse
a. Hypokalemia a. Disinfected managerial activity. The correct allocation and
74. You asked questions as soon as she regained b. Enlargement of the Thryoid gland b. Clean distribution of resources is vital in the harmonious
consciousness from thyroidectomy primarily to c. Nystagmus c. Sterile operation of the financial balance of the agency.
assess the evidence of: d. Excessive salivation d. Alcoholized
a. Thyroid storm 91. Which of the following best defines Budget?
b. Damage to the laryngeal nerve 80. In administering Lugol’s solution, the 86. You are caring for Johnny who is scheduled to a. Plan for the allocation of resources for
c. Mediastinal shift precautionary measure should include: undergo total thyroidectomy because of a future use
d. Hypocalcaemia tetany a. Administer with glass only diagnosis of thyroid cancer. Prior to total b. The process of allocating resources for
b. Dilute with juice and administer with a thyroidectomy, you should instruct Johnny to: future use
75. Should you check for haemorrhage, you will: straw a. Perform range and motion exercise on c. Estimate cost of expenses
a. Slip your hand under the nape of her c. Administer it with milk and drink it the head and neck d. Continuous process in seeing that the
neck d. Follow it with milk of magnesia b. Apply gentle pressure against the goals and objective of the agency is met
b. Check for hypotension incision when swallowing
c. Apply neck collar to prevent Situation: Pharmacological treatment was not effective c. Cough and deep breathe every 2 hours 92. Which of the following best defines Capital
haemorrhage for Johnny’s hyperthyroidism and now, he is scheduled d. Support head with the hands when Budget?
d. Observe the dressing if it is soaked with for Thyroidectomy. changing position a. Budget to estimate the cost of direct
blood labour, number of staff to be hired and
81. Instruments in the surgical suite for surgery is 87. As Johnny’s nurse, you plan to set up emergency necessary number of workers to meet
76. Basal Metabolic rate is assessed on Johnny to classified as either CRITICAL, SEMI CRITICAL and equipment at her bedside following the general patient needs
determine his metabolic rate. In assessing the NON CRITICAL. If the instrument are introduced thyroidectomy. You should include: b. Includes the monthly and daily expenses
BMR using the standard procedure, you need to directly into the blood stream or into any a. An airway and rebreathing tube and expected revenue and expenses
tell Johnny that: normally sterile cavity or area of the body it is b. A tracheostomy set and oxygen c. These are related to long term planning
a. Obstructing his vision classified as: c. A crush cart with bed board and includes major replacement or
b. Restraining his upper and lower a. Critical d. Two ampules of sodium bicarbonate expansion of the plant, major
extremities b. Non Critical equipment and inventories.
c. Obstructing his hearing c. Semi Critical 88. Which of the following nursing interventions is d. These are expenses that are not
d. Obstructing his nostrils with a clamp d. Ultra Critical appropriate after a total thyroidectomy? dependent on the level of production or
a. Place pillows under your patient’s sales. They tend to be time-related, such
77. The BMR is based on the measurement that: 82. Instruments that do not touch the patient or shoulders. as salaries or rents being paid per month
a. Rate of respiration under different have contact only to intact skin is classified as: b. Raise the knee-gatch to 30 degrees
condition of activities and rest a. Critical c. Keep you patient in a high-fowler’s 93. Which of the following best described
b. Amount of oxygen consumption under b. Non Critical position. Operational Budget?
resting condition over a measured c. Semi Critical d. Support the patient’s head and neck a. Budget to estimate the cost of direct
period of time d. Ultra Critical with pillows and sandbags. labour, number of staff to be hired and
c. Amount of oxygen consumption under necessary number of workers to meet
stressed condition over a measured 83. If an instrument is classified as Semi Critical, an 89. If there is an accidental injury to the parathyroid the general patient needs
period of time acceptable method of making the instrument gland during a thyroidectomy which of the b. Includes the monthly and daily
d. Ratio of respiration to pulse rate over a ready for surgery is through: following might Leda develops postoperatively? expenses and expected revenue and
measured period of time a. Sterilization a. Cardiac arrest expenses
b. Disinfection b. Respiratory failure c. These are related to long term planning
78. Her physician ordered lugol’s solution in order c. Decontamination c. Dyspnea and includes major replacement or
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expansion of the plant, major c. The Chinese Triad

equipments and inventories. d. Charcot’s Triad 5. A Client state, “I get down on myself when I
d. These are expenses that are not NURSING PRACTICE V make mistake.” Using Cognitive therapy
dependent on the level of production or 98. Which of the following is true with the Triad approach, the nurse should:
sales. They tend to be time-related, such seen in head injuries? Situation: Understanding different models of care is a A. Teach the client relaxation exercise to
as rent a. Narrowing of Pulse pressure, Cheyne necessary part of the nurse patient relationship. diminish stress
stokes respiration, Tachycardia B. Provide the client with Mastery
94. Which of the following accurately describes a b. Widening Pulse pressure, Irregular 1. The focus of this therapy is to have a positive experience to boost self esteem
Fixed Cost in budgeting? respiration, Bradycardia environmental manipulation, physical and social C. Explore the client’s past experiences that
a. These are usually the raw materials and c. Hypertension, Kussmaul’s respiration, to effect a positive change. causes the illness
labour salaries that depend on the Tachycardia A. Milieu D. Help client modify the belief that
production or sales d. Hypotension, Irregular respiration, B. Psychotherapy anything less than perfect is horrible
b. These are expenses that change in Bradycardia C. Behaviour
proportion to the activity of a business D. Group 6. The most advantageous therapy for a preschool
c. These are expenses that are not 99. In a client with a Cheyne stokes respiration, age child with a history of physical and sexual
dependent on the level of production or which of the following is the most appropriate 2. The client asks the nurse about Milieu therapy. abuse would be:
sales. They tend to be time-related, nursing diagnosis? The nurse responds knowing that the primary A. Play
such as rent a. Ineffective airway clearance focus of milieu therapy can be best described by B. Psychoanalysis
d. This is the summation of the Variable b. Impaired gas exchange which of the following? C. Group
Cost and the Fixed Cost c. Ineffective breathing pattern A. A form of behavior modification therapy D. Family
d. Activity intolerance B. A cognitive approach of changing the
95. Which of the following accurately describes behaviour 7. An 18 year old client is admitted with the
Variable Cost in budgeting? 100. You know the apnea is seen in client’s with C. A living, learning or working diagnosis of anorexia nervosa. A cognitive
a. These are related to long term planning cheyne stokes respiration, APNEA is defined as: environment behavioural approach is used as part of her
and include major replacement or a. Inability to breathe in a supine position D. A behavioural approach to changing treatment plan. The nurse understands that the
expansion of the plant, major so the patient sits up in bed to breathe behaviour purpose of this approach is to:
equipments and inventories. b. The patient is dead, the breathing stops A. Help the client identify and examine
b. These are expenses that change in c. There is an absence of breathing for a 3. A nurse is caring for a client with phobia who is dysfunctional thoughts and beliefs
proportion to the activity of a business period of time, usually 15 seconds or being treated for the condition. The client is B. Emphasize social interaction with clients
c. These are expenses that are not more introduced to short periods of exposure to the who withdraw
dependent on the level of production or d. A period of hypercapnea and hypoxia phobic object while in relaxed state. The nurse C. Provide a supportive environment and a
sales. They tend to be time-related, such due to the cessation of respiratory effort understands that this form of behaviour therapeutic community
as rent inspite of normal respiratory functioning modification can be best described as: D. Examine intrapsychic conflicts and past
d. This is the summation of the Variable A. Systematic desensitization events in life
Cost and the Fixed Cost B. Self-control therapy
C. Aversion Therapy 8. The nurse is preparing to provide reminiscence
Situation – Andrea is admitted to the ER following an D. Operant conditioning therapy for a group of clients. Which of the
assault where she was hit in the face and head. She was following clients will the nurse select for this
brought to the ER by a police woman. Emergency 4. A client with major depression is considering group?
measures were started. cognitive therapy. The client say to the nurse, A. A client who experiences profound
“How does this treatment works?” The nurse depression with moderate cognitive
96. Andrea’s respiration is described as waxing and responds by telling the client that: impairment
waning. You know that this rhythm of respiration A. “This type of treatment helps you B. A catatonic, immobile client with
is defined as: examine how your thoughts and moderate cognitive impairment
a. Biot’s feelings contribute to your difficulties” C. An undifferentiated schizophrenic client
b. Cheyne stokes B. “This type of treatment helps you with moderate cognitive impairment
c. Kussmaul’s examine how your past life has D. A client with mild depression who
d. Eupnea contributed to your problems.” exhibits who demonstrates normal
C. “This type of treatment helps you to cognition
97. What do you call the triad of sign and symptoms confront your fears by exposing you to
seen in a client with increasing ICP? the feared object abruptly. 9. Which intervention would be typical of a nurse
a. Virchow’s Triad D. “This type of treatment will help you using cognitive-behavioral approach to a client
b. Cushing’s Triad relax and develop new coping skills.” experiencing low self-esteem?
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A. Use of unconditional positive regard C. refer the client to the psychiatrist 22. When Mang Jose says to you: “The voices are is best described in one of the following
B. Analysis of free association D. refer the matter to the police telling me bad things again!” The best response statements:
C. Classical conditioning is: A. Unacceptable feelings or behavior are
D. Examination of negative thought Situation: Rose seeks psychiatric consultation because of A. “Whose voices are those?” kept out of awareness by developing the
patterns intense fear of flying in an airplane which has greatly B. “I doubt what the voices are telling you” opposite behavior or emotion
affected her chances of success in her job. C. “I do not hear the voice you say you B. Consciously unacceptable instinctual
10. Which of the following therapies has been hear” drives are diverted into personally and
strongly advocated for the treatment of post- 16. The most common defense mechanism used by D. “Are you sure you hear these voices?” socially acceptable channels
traumatic stress disorders? phobic clients is: C. Something unacceptable already done
A. ECT A. Supression 23. A relevant nursing diagnosis for clients with is symbolically acted out in reverse
B. Group Therapy B. Denial auditory hallucination is: D. Transfer of emotions associated with a
C. Hypnotherapy C. Rationalization A. Sensory perceptual alteration particular person, object or situation to
D. Psychoanalysis D. Displacement B. Altered thought process another less threatening person, object
C. Impaired social interaction or situation
11. The nurse knows that in group therapy, the 17. The goal of the therapy in phobia is: D. Impaired verbal communication
maximum number of members to include is: A. Change her lifestyle 29. To be more effective, the nurse who cares for
A. 4 B. Ignore tension producing situation 24. During mealtime, Jose refused to eat telling that persons with obsessive compulsive disorder
B. 8 C. Change her reaction towards anxiety the food was poisoned. The nurse should: must possess one of the following qualities:
C. 10 D. Eliminate fear producing situations A. Ignore his remark A. Compassion
D. 16 B. Offer him food in his own container B. Patience
18. The therapy most effective for client’s with C. Show him how irrational his thinking is C. Consistency
12. The nurse is providing information to a client phobia is: D. Respect his refusal to eat D. Friendliness
with the use of disulfiram (antabuse) for the A. Hypnotherapy
treatment of alcohol abuse. The nurse B. Cognitive therapy 25. When communicating with Jose, The nurse 30. Persons with OCD usually manifest:
understands that this form of therapy works on C. Group therapy considers the following except: A. Fear
what principle? D. Behavior therapy A. Be warm and enthusiastic B. Apathy
A. Negative Reinforcement B. Refrain from touching Jose C. Suspiciousness
B. Operant Conditioning 19. The fear and anxiety related to phobia is said to C. Do not argue regarding his hallucination D. Anxiety
C. Aversion Therapy be abruptly decreased when the patient is and delusion
D. Gestalt therapy exposed to what is feared through: D. Use simple, clear language Situation: The patient who is depressed will undergo
A. Guided Imagery electroconvulsive therapy.
13. A biological or medical approach in treating B. Systematic desensitization Situation: Gringo seeks psychiatric counselling for his
psychiatric patient is: C. Flooding ritualistic behavior of counting his money as many as 10 31. Studies on biological depression support
A. Million therapy D. Hypotherapy times before leaving home. electroconvulsive therapy as a mode of
B. Behavioral therapy treatment. The rationale is:
C. Somatic therapy 20. Based on the presence of symptom, the 26. An initial appropriate nursing diagnosis is: A. ECT produces massive brain damage
D. Psychotherapy appropriate nursing diagnosis is: A. Impaired social interaction which destroys the specific area
A. Self-esteem disturbance B. Ineffective individual coping containing memories related to the
14. Which of these nursing actions belong to the B. Activity intolerance C. Impaired adjustment events surrounding the development of
secondary level of preventive intervention? C. Impaired adjustment D. Anxiety Moderate psychotic condition
A. Providing mental health consultation to D. Ineffective individual coping B. The treatment serves as a symbolic
health care providers 27. Obsessive compulsive disorder is BEST described punishment for the client who feels
B. Providing emergency psychiatric Situation: Mang Jose, 39 year old farmer, unmarried, had by: guilty and worthless
services been confined in the National center for mental health A. Uncontrollable impulse to perform an C. ECT relieves depression psychologically
C. Being politically active in relation to for three years with a diagnosis of schizophrenia. act or ritual repeatedly by increasing the norepinephrine level
mental health issues B. Persistent thoughts D. ECT is seen as a life-threatening
D. Providing mental health education to 21. The most common defense mechanism used by C. Recurring unwanted and disturbing experience and depressed patients
members of the community a paranoid client is: thought alternating with a behavior mobilize all their bodily defences to deal
A. Displacement D. Pathological persistence of unwilled with this attack.
15. When the nurse identifies a client who has B. Rationalization thought, feeling or impulse
attempted to commit suicide the nurse should: C. Suppression 32. The preparation of a patient for ECT ideally is
A. call a priest D. Projection 28. The defense mechanism used by persons with MOST similar to preparation for a patient for:
B. counsel the client obsessive compulsive disorder is undoing and it A. electroencephalogram
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B. general anesthesia A. Emotional crisis B. Self-esteem disturbance

C. X-ray B. Cholinergic crisis 45. Psychotherapy which is prescribed for Rosana is C. Ineffective individual coping
D. electrocardiogram C. Menopausal crisis described as; D. Defensive coping
D. Myasthenia crisis A. Establishing an environment adapted to
33. Which of the following is a possible side effect an individual patient needs 50. Most appropriate nursing intervention for a
which you will discuss with the patient? 40. If you are not extra careful and by chance you B. Sustained interaction between the client with suspicious behavior is one of the
A. hemorrhage within the brain give over medication, this would lead to; therapist and client to help her develop following;
B. encephalitis A. Cholinergic crisis more functional behaviour A. Talk to the client constantly to reinforce
C. robot-like body stiffness B. Menopausal crisis C. Using dramatic techniques to portray reality
D. confusion, disorientation and short C. Emotional crisis interpersonal conflicts B. Involve him in competitive activities
term memory loss D. Myasthenia crisis D. Biologic treatment for mental disorder C. Use Non Judgmental and Consistent
approach
34. Informed consent is necessary for the treatment Situation: Rosanna 20 y/o unmarried patient believes Situation: Dennis 40 y/o married man, an electrical D. Project cheerfulness in interacting with
for involuntary clients. When this cannot be that the toilet for the female patient in contaminated engineer was admitted with the diagnosis of paranoid the patient
obtained, permission may be taken from the: with AIDS virus and refuses to use it unless she flushes it disorders. He has become suspicious and distrustful 2
A. social worker three times and wipes the seat same number of times months before admission. Upon admission, he kept on Situation: Clients with Bipolar disorder receives a very
B. next of kin or guardian with antiseptic solution. saying, “my wife has been planning to kill me.” high nursing attention due to the increasing rate of
C. doctor suicide related to the illness.
D. chief nurse 41. The fear of using “contaminated” toilet seat can 46. A paranoid individual who cannot accept the
be attributed to Rosanna’s inability to; guilt demonstrate one of the following defense 51. The nurse is assigned to care for a recently
35. After ECT, the nurse should do this action before A. Adjust to a strange environment mechanism; admitted client who has attempted suicide.
giving the client fluids, food or medication: B. Express her anxiety A. Denial What should the nurse do?
A. assess the gag reflex C. Develop the sense of trust in other B. Projection A. Search the client's belongings and room
B. next of kin or guardian person C. Rationalization carefully for items that could be used to
C. assess the sensorium D. Control unacceptable impulses or D. Displacement attempt suicide.
D. check O2 Sat with a pulse oximeter feelings B. Express trust that the client won't cause
47. One morning, Dennis was seen tilting his head as self-harm while in the facility.
Situation: Mrs Ethel Agustin 50 y/o, teacher is afflicted 42. Assessment data upon admission help the nurse if he was listening to someone. An appropriate C. Respect the client's privacy by not
with myasthenia gravis. to identify this appropriate nursing diagnosis nursing intervention would be; searching any belongings.
A. Ineffective denial A. Tell him to socialize with other patient to D. Remind all staff members to check on
36. Looking at Mrs Agustin, your assessment would B. Impaired adjustment divert his attention the client frequently.
include the following except; C. Ineffective individual coping B. Involve him in group activities
A. Nystagmus D. Impaired social interaction C. Address him by name to ask if he is 52. In planning activities for the depressed client,
B. Difficulty of hearing hearing voices again especially during the early stages of
C. Weakness of the levator palpebrae 43. An effective nursing intervention to help Rosana D. Request for an order of antipsychotic hospitalization, which of the following plan is
D. Weakness of the ocular muscle is; medicine best?
A. Convincing her to use the toilet after the A. Provide an activity that is quiet and
37. In an effort to combat complications which nurse has used it first 48. When he says, “these voices are telling me my solitary to avoid increased fatigue such
might occur relatives should he taught; B. Explaining to her that AIDS cannot be wife is going to kill me.” A therapeutic as working on a puzzle and reading a
A. Checking cardiac rate transmitted by using the toilet communication of the nurse is which one of the book.
B. Taking blood pressure reading C. Allowing her to flush and clear the following; B. Plan nothing until the client asks to
C. Techniques of oxygen inhalation toilet seat until she can manage her A. “i do not hear the voices you say you participate in the milieu
D. Administration of oxygen inhalation anxiety hear” C. Offer the client a menu of daily activities
D. Explaining to her how AIDS is B. “are you really sure you heard those and ask the client to participate in all of
38. The drug of choice for her condition is; transmitted voices?” them
A. Prostigmine C. “I do not think you heard those D. Provide a structured daily program of
B. Morphine 44. The goal for treatment for Rosana must be voices?” activities and encourage the client to
C. Codeine directed toward helping her to; D. “Whose voices are those?” participate
D. Prednisone A. Walk freely about her past experience
B. Develop trusting relationship with others 49. The nurse confirms that Dennis is manifesting 53. A client with a diagnosis of major depression,
39. As her nurse, you have to be cautious about C. Gain insight that her behaviour is due auditory hallucination. The appropriate nursing recurrent with psychotic features is admitted to
administration of medication, if she is under to feeling of anxiety diagnosis she identifiesis; the mental health unit. To create a safe
medicated this can cause; D. Accept the environment unconditionally A. Sensory perceptual alteration environment for the client, the nurse most
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importantly devises a plan of care that deals The nurse would initially: problem. After the identification of the research
specifically with the clients: A. Ask the client to leave the group session 62. It is essential in desensitization for the patient problem, which of the following should be done?
A. Disturbed thought process B. Tell the client that she will not be to: A. Methodology
B. Imbalanced nutrition allowed to attend any more group A. Have rapport with the therapist B. Acknowledgement
C. Self-Care Deficit sessions B. Use deep breathing or another C. Review of related literature
D. Deficient Knowledge C. Tell the client that she needs to allow relaxation technique D. Formulate hypothesis
other client in a group time to talk C. Assess one’s self for the need of an
54. The client is taking a Tricyclic anti-depressant, D. Ask another nurse to escort the client anxiolytic drug 68. Which of the following communicate the results
which of the following is an example of TCA? out of the group session D. Work through unresolved unconscious of the research to the readers. They facilitate the
A. Paxil conflicts description of the data.
B. Nardil 59. A professional artist is admitted to the A. Hypothesis
C. Zoloft psychiatric unit for treatment of bipolar 63. In this level of anxiety, cognitive capacity B. Research problem
D. Pamelor disorder. During the last 2 weeks, the client has diminishes. Focus becomes limited and client C. Statistics
created 154 paintings, slept only 2 to 3 hours experiences tunnel vision. Physical signs of D. Tables and Graphs
55. A client visits the physician's office to seek every 2 days, and lost 18 lb (8.2 kg). Based on anxiety become more pronounced.
treatment for depression, feelings of Maslow's hierarchy of needs, what should the A. Severe anxiety 69. In Quantitative date, which of the following is
hopelessness, poor appetite, insomnia, fatigue, nurse provide this client with first? B. Mild anxiety described as the distance in the scoring unites of
low self-esteem, poor concentration, and A. The opportunity to explore family C. Panic the variable from the highest to the lower?
difficulty making decisions. The client states that dynamics D. Moderate anxiety A. Frequency
these symptoms began at least 2 years ago. B. Help with re-establishing a normal B. Median
Based on this report, the nurse suspects: sleep pattern 64. Antianxiety medications should be used with C. Mean
A. cyclothymic disorder. C. Experiences that build self-esteem extreme caution because long term use can lead D. Range
B. Bipolar disorder D. Art materials and equipment to:
C. major depression. A. Parkinsonian like syndrome 70. This expresses the variability of the data in
D. dysthymic disorder. 60. The physician orders lithium carbonate B. Hepatic failure reference to the mean. It provides as with a
(Lithonate) for a client who's in the manic phase C. Hypertensive crisis numerical estimate of how far, on the average
56. The nurse is planning activities for a client who of bipolar disorder. During lithium therapy, the D. Risk of addiction the separate observation are from the mean:
has bipolar disorder, which aggressive social nurse should watch for which adverse reactions? A. Mode
behaviour. Which of the following activities A. Anxiety, restlessness, and sleep 65. The nursing management of anxiety related with B. Median
would be most appropriate for this client? disturbance post-traumatic stress disorder includes all of the C. Standard deviation
A. Ping Pong B. Nausea, diarrhea, tremor, and lethargy following EXCEPT: D. Frequency
B. Linen delivery C. Constipation, lethargy, and ataxia A. Encourage participation in recreation or
C. Chess D. Weakness, tremor, and urine retention sports activities Situation: Survey and Statistics are important part of
D. Basketball B. Reassure client’s safety while touching research that is necessary to explain the characteristics
Situation – Annie has a morbid fear of heights. She asks client of the population.
57. The nurse assesses a client with admitted the nurse what desensitization therapy is: C. Speak in a calm soothing voice
diagnosis of bipolar affective disorder, mania. D. Remain with the client while fear level is 71. According to the WHO statistics on the Homeless
The symptom presented by the client that 61. The accurate information of the nurse of the high population around the world, which of the
requires the nurse’s immediate intervention is goal of desensitization is: following groups of people in the world
the client’s: A. To help the clients relax and SITUATION: You are fortunate to be chosen as part of disproportionately represents the homeless
A. Outlandish behaviour and inappropriate progressively work up a list of anxiety the research team in the hospital. A review of the population?
dress provoking situations through imagery. following IMPORTANT nursing concepts was made. A. Hispanics
B. Grandiose delusion of being a royal B. To provide corrective emotional B. Asians
descendant of king arthut experiences through a one-to-one 66. As a professional, a nurse can do research for C. African Americans
C. Nonstop physical activity and poor intensive relationship. varied reason except: D. Caucasians
nutritional intake C. To help clients in a group therapy setting A. Professional advancement through
D. Constant incessant talking that includes to take on specific roles and reenact in research participation 72. All but one of the following is not a measure of
sexual topics and teasing the staff front of an audience, situations in which B. To validate results of new nursing Central Tendency:
interpersonal conflict is involved. modalities A. Mode
58. A nurse is conducting a group therapy session D. To help clients cope with their problems C. For financial gains B. Standard Deviation
and during the session, A client with mania by learning behaviors that are more D. To improve nursing care C. Variance
consistently talks and dominates the group. The functional and be better equipped to D. Range
behaviour is disrupting the group interaction. face reality and make decisions. 67. Each nurse participants was asked to identify a
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73. In the value: 87, 85, 88, 92, 90; what is the A. There is a control group E. What are the differences of the support 87. Which of the following studies is based on
mean? B. There is an experimental group system being received by patient with quantitative research?
A. 88.2 C. Selection of subjects in the control group chronic illness and patients with acute A. A study examining the bereavement
B. 88.4 is randomized illness? process in spouse of clients with
C. 87 D. There is a careful selection of subjects terminal cancer
D. 90 in the experimental group 83. You would like to compare the support system B. A study exploring the factors influencing
of patients with chronic illness to those with weight control behaviour
74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; what 80. The researcher implemented a medication acute illness. Considering that the hypothesis C. A Study measuring the effects of sleep
is the mode? regimen using a new type of combination drugs was: “Client’s with chronic illness have lesser deprivation on wound healing
A. 80 to manic patients while another group of manic support system than client’s with acute illness.” D. A study examining client’s feelings
B. 82 patient receives the routine drugs. The What type of research is this? before, during and after bone marrow
C. 90 researcher however handpicked the A. Descriptive aspiration.
D. 85.5 experimental group for they are the clients with B. Correlational, Non experimental
75. In the value: 80, 80, 10, 10, 25, 65, 100, 200; multiple episodes of bipolar disorder. The C. Experimental 88. Which of the following studies is based on the
what is the median? researcher utilized which research design? D. Quasi Experimental qualitative research?
A. 71.25 A. Quasi-experimental A. A study examining clients’ reaction to
B. 22.5 B. Phenomenological 84. In any research study where individual persons stress after open heart surgery
C. 10 and 25 C. Pure experimental are involved, it is important that an informed B. A study measuring nutrition and weight
D. 72.5 D. Longitudinal consent of the study is obtained. The following loss/gain in clients with cancer
are essential information about the consent that C. A study examining oxygen levels after
76. Draw Lots, Lottery, Table of random numbers or Situation 19: As a nurse, you are expected to participate you should disclose to the prospective subjects endotracheal suctioning
a sampling that ensures that each element of the in initiating or participating in the conduct of research except: D. A study measuring differences in blood
population has an equal and independent studies to improve nursing practice. You to be updated A. Consent to incomplete disclosure pressure before, during and after
chance of being chosen is called: on the latest trends and issues affected the profession B. Description of benefits, risks and procedure
A. Cluster and the best practices arrived at by the profession. discomforts
B. Stratified C. Explanation of procedure 89. An 85 year old client in a nursing home tells a
C. Simple 81. You are interested to study the effects of D. Assurance of anonymity and nurse, “I signed the papers of that research
D. Systematic mediation and relaxation on the pain confidentiality study because the doctor was so insistent and I
experienced by cancer patients. What type of want him to continue taking care for me” Which
77. An investigator wants to determine some of the variable is pain? 85. In the Hypothesis: “The utilization of technology client right is being violated?
problems that are experienced by diabetic A. Dependent in teaching improves the retention and attention A. Right of self determination
clients when using an insulin pump. The B. Independent of the nursing students.” Which is the B. Right to full disclosure
investigator went into a clinic where he C. Correlational dependent variable? C. Right to privacy and confidentiality
personally knows several diabetic clients having D. Demographic A. Utilization of technology D. Right not to be harmed
problem with insulin pump. The type of sampling B. Improvement in the retention and
done by the investigator is called: 82. You would like to compare the support system attention 90. A supposition or system of ideas that is
A. Probability of patient with chronic illness to those with C. Nursing students proposed to explain a given phenomenon best
B. Snowball acute illness. How will you best state your D. Teaching defines:
C. Purposive problem? A. A paradigm
D. Incidental A. A descriptive study to compare the Situation: You are actively practicing nurse who has just B. A theory
support system of patients with chronic finished you graduate studies. You learned the value of C. A Concept
78. If the researcher implemented a new structured illness and those with acute illness in research and would like to utilize the knowledge and D. A conceptual framework
counselling program with a randomized group of terms of demographic data and skills gained in the application of research to the nursing Situation: Mastery of research design determination is
subject and a routine counselling program with knowledge about intervention. service. The following questions apply to research. essential in passing the NLE.
another randomized group of subject, the B. The effects of the types of support
research is utilizing which design? system of patients with chronic illness 86. Which type of research inquiry investigates the 91. Ana wants to know if the length of time she will
A. Quasi experimental and those with acute illness. issues of human complexity (e.g understanding study for the board examination is proportional
B. Comparative C. A comparative analysis of the support the human expertise)? to her board rating. During the June 2008 board
C. Experimental system of patients with chronic illness A. Logical position examination, she studied for 6 months and
D. Methodological and those with acute illness. B. Positivism gained 68%, On the next board exam, she
D. A study to compare the support system C. Naturalistic inquiry studied for 6 months again for a total of 1 year
79. Which of the following is not true about a Pure of patients with chronic illness and those D. Quantitative research and gained 74%, On the third board exam, She
Experimental research? with acute illness. studied for 6 months for a total of 1 and a half
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year and gained 82%. The research design she collected 100 random individuals and determine TEST I - Foundation of Professional Nursing 5. Nurse Betty is assigned to the following clients.
used is: who is their favourite comedian actor. 50% said Practice The client that the nurse would see first after
A. Comparative Dolphy, 20% said Vic Sotto, while some endorsement?
B. Experimental answered Joey de Leon, Allan K, Michael V. 1. The nurse In-charge in labor and delivery unit a. A 34 year-old post-operative
C. Correlational Tonyo conducted what type of research study? administered a dose of terbutaline to a client appendectomy client of five hours who
D. Qualitative A. Phenomenological without checking the client’s pulse. The standard is complaining of pain.
B. Non experimental that would be used to determine if the nurse b. A 44 year-old myocardial infarction (MI)
92. Anton was always eating high fat diet. You want C. Case Study was negligent is: client who is complaining of nausea.
to determine if what will be the effect of high D. Survey a. The physician’s orders. c. A 26 year-old client admitted for
cholesterol food to Anton in the next 10 years. b. The action of a clinical nurse specialist dehydration whose intravenous (IV) has
You will use: 98. Jane visited a tribe located somewhere in China, who is recognized expert in the field. infiltrated.
A. Comparative it is called the Shin Jea tribe. She studied the way c. The statement in the drug literature d. A 63 year-old post operative’s
B. Historical of life, tradition and the societal structure of about administration of terbutaline. abdominal hysterectomy client of three
C. Correlational these people. Jane will best use which research d. The actions of a reasonably prudent days whose incisional dressing is
D. Longitudinal design? nurse with similar education and saturated with serosanguinous fluid.
A. Historical experience.
93. Community A was selected randomly as well as B. Phenomenological 6. Nurse Gail places a client in a four-point restraint
community B, nurse Edna conducted teaching to C. Case Study 2. Nurse Trish is caring for a female client with a following orders from the physician. The client
community A and assess if community A will D. Ethnographic history of GI bleeding, sickle cell disease, and a care plan should include:
have a better status than community B. This is platelet count of 22,000/μl. The female client is a. Assess temperature frequently.
an example of: 99. Anjoe researched on TB. Its transmission, dehydrated and receiving dextrose 5% in half- b. Provide diversional activities.
A. Comparative Causative agent and factors, treatment sign and normal saline solution at 150 ml/hr. The client c. Check circulation every 15-30 minutes.
B. Experimental symptoms as well as medication and all other in complains of severe bone pain and is scheduled d. Socialize with other patients once a shift.
C. Correlational depth information about tuberculosis. This study to receive a dose of morphine sulfate. In
D. Qualitative is best suited for which research design? administering the medication, Nurse Trish 7. A male client who has severe burns is receiving
A. Historical should avoid which route? H2 receptor antagonist therapy. The nurse In-
94. Ana researched on the development of a new B. Phenomenological a. I.V charge knows the purpose of this therapy is to:
way to measure intelligence by creating a 100 C. Case Study b. I.M a. Prevent stress ulcer
item questionnaire that will assess the cognitive D. Ethnographic c. Oral b. Block prostaglandin synthesis
skills of an individual. The design best suited for d. S.C c. Facilitate protein synthesis.
this study is: 100. Diana is to conduct a study about the d. Enhance gas exchange
A. Historical relationship of the number of family members in 3. Dr. Garcia writes the following order for the
B. Survey the household and the electricity bill. Which of client who has been recently admitted “Digoxin 8. The doctor orders hourly urine output
C. Methodological the following is the best research design suited .125 mg P.O. once daily.” To prevent a dosage measurement for a postoperative male client.
D. Case study for this study? error, how should the nurse document this order The nurse Trish records the following amounts of
1. Descriptive onto the medication administration record? output for 2 consecutive hours: 8 a.m.: 50 ml; 9
95. Gen is conducting a research study on how mark, 2. Exploratory a. “Digoxin .1250 mg P.O. once daily” a.m.: 60 ml. Based on these amounts, which
an AIDS client lives his life. A design suited for 3. Explanatory b. “Digoxin 0.1250 mg P.O. once daily” action should the nurse take?
this is: 4. Correlational c. “Digoxin 0.125 mg P.O. once daily” a. Increase the I.V. fluid infusion rate
A. Historical 5. Comparative d. “Digoxin .125 mg P.O. once daily” b. Irrigate the indwelling urinary catheter
B. Phenomenological 6. Experimental c. Notify the physician
C. Case Study A. 1,4 4. A newly admitted female client was diagnosed d. Continue to monitor and record hourly
D. Ethnographic B. 2,5 with deep vein thrombosis. Which nursing urine output
C. 3,6 diagnosis should receive the highest priority?
96. Marco is to perform a study about how nurses D. 1,5 a. Ineffective peripheral tissue perfusion 9. Tony, a basketball player twist his right ankle
perform surgical asepsis during World War II. A E. 2,4 related to venous congestion. while playing on the court and seeks care for
design best for this study is: b. Risk for injury related to edema. ankle pain and swelling. After the nurse applies
A. Historical c. Excess fluid volume related to peripheral ice to the ankle for 30 minutes, which statement
B. Phenomenological vascular disease. by Tony suggests that ice application has been
C. Case Study d. Impaired gas exchange related to effective?
D. Ethnographic increased blood flow. a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
97. Tonyo conducts sampling at barangay 412. He c. “My ankle appears redder now”.
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d. “I need something stronger for pain d. Pulling the lobule down and forward b. Call the radiology department for X-ray. c. 1.5 cc
relief” c. Reassure the client that everything will d. 2.5 cc
16. Which instruction should nurse Tom give to a be alright.
10. The physician prescribes a loop diuretic for a male client who is having external radiation d. Immobilize the leg before moving the 27. A child of 10 years old is to receive 400 cc of IV
client. When administering this drug, the nurse therapy: client. fluid in an 8 hour shift. The IV drip factor is 60.
anticipates that the client may develop which a. Protect the irritated skin from sunlight. The IV rate that will deliver this amount is:
electrolyte imbalance? b. Eat 3 to 4 hours before treatment. 22. A male client is being transferred to the nursing a. 50 cc/ hour
a. Hypernatremia c. Wash the skin over regularly. unit for admission after receiving a radium b. 55 cc/ hour
b. Hyperkalemia d. Apply lotion or oil to the radiated area implant for bladder cancer. The nurse in-charge c. 24 cc/ hour
c. Hypokalemia when it is red or sore. would take which priority action in the care of d. 66 cc/ hour
d. Hypervolemia this client?
17. In assisting a female client for immediate a. Place client on reverse isolation. 28. The nurse is aware that the most important
11. She finds out that some managers have surgery, the nurse In-charge is aware that she b. Admit the client into a private room. nursing action when a client returns from
benevolent-authoritative style of management. should: c. Encourage the client to take frequent surgery is:
Which of the following behaviors will she exhibit a. Encourage the client to void following rest periods. a. Assess the IV for type of fluid and rate of
most likely? preoperative medication. d. Encourage family and friends to visit. flow.
a. Have condescending trust and b. Explore the client’s fears and anxieties b. Assess the client for presence of pain.
confidence in their subordinates. about the surgery. 23. A newly admitted female client was diagnosed c. Assess the Foley catheter for patency
b. Gives economic and ego awards. c. Assist the client in removing dentures with agranulocytosis. The nurse formulates and urine output
c. Communicates downward to staffs. and nail polish. which priority nursing diagnosis? d. Assess the dressing for drainage.
d. Allows decision making among d. Encourage the client to drink water prior a. Constipation
subordinates. to surgery. b. Diarrhea 29. Which of the following vital sign assessments
c. Risk for infection that may indicate cardiogenic shock after
12. Nurse Amy is aware that the following is true 18. A male client is admitted and diagnosed with d. Deficient knowledge myocardial infarction?
about functional nursing acute pancreatitis after a holiday celebration of a. BP – 80/60, Pulse – 110 irregular
a. Provides continuous, coordinated and excessive food and alcohol. Which assessment 24. A male client is receiving total parenteral b. BP – 90/50, Pulse – 50 regular
comprehensive nursing services. finding reflects this diagnosis? nutrition suddenly demonstrates signs and c. BP – 130/80, Pulse – 100 regular
b. One-to-one nurse patient ratio. a. Blood pressure above normal range. symptoms of an air embolism. What is the d. BP – 180/100, Pulse – 90 irregular
c. Emphasize the use of group b. Presence of crackles in both lung fields. priority action by the nurse?
collaboration. c. Hyperactive bowel sounds a. Notify the physician. 30. Which is the most appropriate nursing action in
d. Concentrates on tasks and activities. d. Sudden onset of continuous epigastric b. Place the client on the left side in the obtaining a blood pressure measurement?
and back pain. Trendelenburg position. a. Take the proper equipment, place the
13. Which type of medication order might read c. Place the client in high-Fowlers position. client in a comfortable position, and
"Vitamin K 10 mg I.M. daily × 3 days?" 19. Which dietary guidelines are important for nurse d. Stop the total parenteral nutrition. record the appropriate information in
a. Single order Oliver to implement in caring for the client with the client’s chart.
b. Standard written order burns? 25. Nurse May attends an educational conference b. Measure the client’s arm, if you are not
c. Standing order a. Provide high-fiber, high-fat diet on leadership styles. The nurse is sitting with a sure of the size of cuff to use.
d. Stat order b. Provide high-protein, high-carbohydrate nurse employed at a large trauma center who c. Have the client recline or sit comfortably
diet. states that the leadership style at the trauma in a chair with the forearm at the level of
14. A female client with a fecal impaction frequently c. Monitor intake to prevent weight gain. center is task-oriented and directive. The nurse the heart.
exhibits which clinical manifestation? d. Provide ice chips or water intake. determines that the leadership style used at the d. Document the measurement, which
a. Increased appetite trauma center is: extremity was used, and the position
b. Loss of urge to defecate 20. Nurse Hazel will administer a unit of whole a. Autocratic. that the client was in during the
c. Hard, brown, formed stools blood, which priority information should the b. Laissez-faire. measurement.
d. Liquid or semi-liquid stools nurse have about the client? c. Democratic.
a. Blood pressure and pulse rate. d. Situational 31. Asking the questions to determine if the person
15. Nurse Linda prepares to perform an otoscopic b. Height and weight. 26. The physician orders DS 500 cc with KCl 10 understands the health teaching provided by the
examination on a female client. For proper c. Calcium and potassium levels mEq/liter at 30 cc/hr. The nurse in-charge is nurse would be included during which step of
visualization, the nurse should position the d. Hgb and Hct levels. going to hang a 500 cc bag. KCl is supplied 20 the nursing process?
client's ear by: 21. Nurse Michelle witnesses a female client sustain mEq/10 cc. How many cc’s of KCl will be added
a. Pulling the lobule down and back a fall and suspects that the leg may be broken. to the IV solution? a. Assessment
b. Pulling the helix up and forward The nurse takes which priority action? a. .5 cc b. Evaluation
c. Pulling the helix up and back a. Takes a set of vital signs. b. 5 cc c. Implementation
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d. Planning and goals “Meperidine, 100 mg/ml.” How many milliliters c. State the client’s name out loud and c. Every 2 years
of meperidine should the client receive? wait a client to repeat it. d. Once, to establish baseline
32. Which of the following item is considered the a. 0.75 d. Check the room number and the client’s
single most important factor in assisting the b. 0.6 name on the bed. 49. A male client has the following arterial blood gas
health professional in arriving at a diagnosis or c. 0.5 values: pH 7.30; Pao2 89 mmHg; Paco2 50
determining the person’s needs? d. 0.25 43. The physician orders dextrose 5 % in water, mmHg; and HCO3 26mEq/L. Based on these
a. Diagnostic test results 1,000 ml to be infused over 8 hours. The I.V. values, Nurse Patricia should expect which
b. Biographical date 38. A male client with diabetes mellitus is receiving tubing delivers 15 drops/ml. Nurse John should condition?
c. History of present illness insulin. Which statement correctly describes an run the I.V. infusion at a rate of: a. Respiratory acidosis
d. Physical examination insulin unit? a. 30 drops/minute b. Respiratory alkalosis
a. It’s a common measurement in the b. 32 drops/minute c. Metabolic acidosis
33. In preventing the development of an external metric system. c. 20 drops/minute d. Metabolic alkalosis
rotation deformity of the hip in a client who b. It’s the basis for solids in the avoirdupois d. 18 drops/minute
must remain in bed for any period of time, the system. 50. Nurse Len refers a female client with terminal
most appropriate nursing action would be to c. It’s the smallest measurement in the 44. If a central venous catheter becomes cancer to a local hospice. What is the goal of this
use: apothecary system. disconnected accidentally, what should the referral?
a. Trochanter roll extending from the crest d. It’s a measure of effect, not a standard nurse in-charge do immediately? a. To help the client find appropriate
of the ileum to the mid-thigh. measure of weight or quantity. a. Clamp the catheter treatment options.
b. Pillows under the lower legs. b. Call another nurse b. To provide support for the client and
c. Footboard 39. Nurse Oliver measures a client’s temperature at c. Call the physician family in coping with terminal illness.
d. Hip-abductor pillow 102° F. What is the equivalent Centigrade d. Apply a dry sterile dressing to the site. c. To ensure that the client gets counseling
temperature? regarding health care costs.
34. Which stage of pressure ulcer development does a. 40.1 °C 45. A female client was recently admitted. She has d. To teach the client and family about
the ulcer extend into the subcutaneous tissue? b. 38.9 °C fever, weight loss, and watery diarrhea is being cancer and its treatment.
a. Stage I c. 48 °C admitted to the facility. While assessing the
b. Stage II d. 38 °C client, Nurse Hazel inspects the client’s abdomen 51. When caring for a male client with a 3-cm stage I
c. Stage III 40. The nurse is assessing a 48-year-old client who and notice that it is slightly concave. Additional pressure ulcer on the coccyx, which of the
d. Stage IV has come to the physician’s office for his annual assessment should proceed in which order: following actions can the nurse institute
physical exam. One of the first physical signs of a. Palpation, auscultation, and percussion. independently?
35. When the method of wound healing is one in aging is: b. Percussion, palpation, and auscultation. a. Massaging the area with an astringent
which wound edges are not surgically a. Accepting limitations while developing c. Palpation, percussion, and auscultation. every 2 hours.
approximated and integumentary continuity is assets. d. Auscultation, percussion, and palpation. b. Applying an antibiotic cream to the area
restored by granulations, the wound healing is b. Increasing loss of muscle tone. three times per day.
termed c. Failing eyesight, especially close vision. 46. Nurse Betty is assessing tactile fremitus in a c. Using normal saline solution to clean the
a. Second intention healing d. Having more frequent aches and pains. client with pneumonia. For this examination, ulcer and applying a protective dressing
b. Primary intention healing nurse Betty should use the: as necessary.
c. Third intention healing 41. The physician inserts a chest tube into a female a. Fingertips d. Using a povidone-iodine wash on the
d. First intention healing client to treat a pneumothorax. The tube is b. Finger pads ulceration three times per day.
connected to water-seal drainage. The nurse in- c. Dorsal surface of the hand 52. Nurse Oliver must apply an elastic bandage to a
36. An 80-year-old male client is admitted to the charge can prevent chest tube air leaks by: d. Ulnar surface of the hand client’s ankle and calf. He should apply the
hospital with a diagnosis of pneumonia. Nurse a. Checking and taping all connections. bandage beginning at the client’s:
Oliver learns that the client lives alone and b. Checking patency of the chest tube. 47. Which type of evaluation occurs continuously a. Knee
hasn’t been eating or drinking. When assessing c. Keeping the head of the bed slightly throughout the teaching and learning process? b. Ankle
him for dehydration, nurse Oliver would expect elevated. a. Summative c. Lower thigh
to find: d. Keeping the chest drainage system b. Informative d. Foot
a. Hypothermia below the level of the chest. c. Formative
b. Hypertension d. Retrospective 53. A 10 year old child with type 1 diabetes develops
c. Distended neck veins 42. Nurse Trish must verify the client’s identity 48. A 45 year old client, has no family history of diabetic ketoacidosis and receives a continuous
d. Tachycardia before administering medication. She is aware breast cancer or other risk factors for this insulin infusion. Which condition represents the
that the safest way to verify identity is to: disease. Nurse John should instruct her to have greatest risk to this child?
37. The physician prescribes meperidine (Demerol), a. Check the client’s identification band. mammogram how often? a. Hypernatremia
75 mg I.M. every 4 hours as needed, to control a b. Ask the client to state his name. a. Twice per year b. Hypokalemia
client’s postoperative pain. The package insert is b. Once per year c. Hyperphosphatemia
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d. Hypercalcemia d. Obtaining the specimen from the urinary incorrect information was documented. How a. Prone with head turned toward the side
drainage bag. does the nurse correct this error? supported by a pillow.
54. Nurse Len is administering sublingual nitrglycerin a. Erases the error and writes in the correct b. Sims’ position with the head of the bed
(Nitrostat) to the newly admitted client. 59. Nurse Meredith is in the process of giving a information. flat.
Immediately afterward, the client may client a bed bath. In the middle of the b. Uses correction fluid to cover up the c. Right side-lying with the head of the bed
experience: procedure, the unit secretary calls the nurse on incorrect information and writes in the elevated 45 degrees.
a. Throbbing headache or dizziness the intercom to tell the nurse that there is an correct information. d. Left side-lying with the head of the bed
b. Nervousness or paresthesia. emergency phone call. The appropriate nursing c. Draws one line to cross out the incorrect elevated 45 degrees.
c. Drowsiness or blurred vision. action is to: information and then initials the change.
d. Tinnitus or diplopia. a. Immediately walk out of the client’s d. Covers up the incorrect information 67. Nurse John develops methods for data
room and answer the phone call. completely using a black pen and writes gathering. Which of the following criteria of a
b. Cover the client, place the call light in the correct information good instrument refers to the ability of the
55. Nurse Michelle hears the alarm sound on the within reach, and answer the phone call. instrument to yield the same results upon its
telemetry monitor. The nurse quickly looks at c. Finish the bed bath before answering 63. Nurse Ron is assisting with transferring a client repeated administration?
the monitor and notes that a client is in a the phone call. from the operating room table to a stretcher. To a. Validity
ventricular tachycardia. The nurse rushes to the d. Leave the client’s door open so the client provide safety to the client, the nurse should: b. Specificity
client’s room. Upon reaching the client’s can be monitored and the nurse can a. Moves the client rapidly from the table c. Sensitivity
bedside, the nurse would take which action answer the phone call. to the stretcher. d. Reliability
first? b. Uncovers the client completely before
a. Prepare for cardioversion 60. Nurse Janah is collecting a sputum specimen for transferring to the stretcher. 68. Harry knows that he has to protect the rights of
b. Prepare to defibrillate the client culture and sensitivity testing from a client who c. Secures the client safety belts after human research subjects. Which of the following
c. Call a code has a productive cough. Nurse Janah plans to transferring to the stretcher. actions of Harry ensures anonymity?
d. Check the client’s level of consciousness implement which intervention to obtain the d. Instructs the client to move self from the a. Keep the identities of the subject secret
specimen? table to the stretcher. b. Obtain informed consent
56. Nurse Hazel is preparing to ambulate a female a. Ask the client to expectorate a small c. Provide equal treatment to all the
client. The best and the safest position for the amount of sputum into the emesis basin. 64. Nurse Myrna is providing instructions to a subjects of the study.
nurse in assisting the client is to stand: b. Ask the client to obtain the specimen nursing assistant assigned to give a bed bath to a d. Release findings only to the participants
a. On the unaffected side of the client. after breakfast. client who is on contact precautions. Nurse of the study
b. On the affected side of the client. c. Use a sterile plastic container for Myrna instructs the nursing assistant to use
c. In front of the client. obtaining the specimen. which of the following protective items when 69. Patient’s refusal to divulge information is a
d. Behind the client. d. Provide tissues for expectoration and giving bed bath? limitation because it is beyond the control of
obtaining the specimen. a. Gown and goggles Tifanny”. What type of research is appropriate
57. Nurse Janah is monitoring the ongoing care b. Gown and gloves for this study?
given to the potential organ donor who has been 61. Nurse Ron is observing a male client using a c. Gloves and shoe protectors a. Descriptive- correlational
diagnosed with brain death. The nurse walker. The nurse determines that the client is d. Gloves and goggles b. Experiment
determines that the standard of care had been using the walker correctly if the client: c. Quasi-experiment
maintained if which of the following data is a. Puts all the four points of the walker flat 65. Nurse Oliver is caring for a client with impaired d. Historical
observed? on the floor, puts weight on the hand mobility that occurred as a result of a stroke. The
a. Urine output: 45 ml/hr pieces, and then walks into it. client has right sided arm and leg weakness. The 70. Nurse Ronald is aware that the best tool for data
b. Capillary refill: 5 seconds b. Puts weight on the hand pieces, moves nurse would suggest that the client use which of gathering is?
c. Serum pH: 7.32 the walker forward, and then walks into the following assistive devices that would a. Interview schedule
d. Blood pressure: 90/48 mmHg it. provide the best stability for ambulating? b. Questionnaire
c. Puts weight on the hand pieces, slides a. Crutches c. Use of laboratory data
58. Nurse Amy has an order to obtain a urinalysis the walker forward, and then walks into b. Single straight-legged cane d. Observation
from a male client with an indwelling urinary it. c. Quad cane
catheter. The nurse avoids which of the d. Walks into the walker, puts weight on d. Walker 71. Monica is aware that there are times when only
following, which contaminate the specimen? the hand pieces, and then puts all four manipulation of study variables is possible and
a. Wiping the port with an alcohol swab points of the walker flat on the floor. 66. A male client with a right pleural effusion noted the elements of control or randomization are
before inserting the syringe. on a chest X-ray is being prepared for not attendant. Which type of research is
b. Aspirating a sample from the port on the 62. Nurse Amy has documented an entry regarding thoracentesis. The client experiences severe referred to this?
drainage bag. client care in the client’s medical record. When dizziness when sitting upright. To provide a safe a. Field study
c. Clamping the tubing of the drainage bag. checking the entry, the nurse realizes that environment, the nurse assists the client to b. Quasi-experiment
which position for the procedure? c. Solomon-Four group design
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d. Post-test only design d. Will remain unable to practice 82. John plans to use a Likert Scale to his study to
professional nursing determine the: 89. Nurse Marian is preparing to administer a blood
72. Cherry notes down ideas that were derived from a. Degree of agreement and disagreement transfusion. Which action should the nurse take
the description of an investigation written by the 77. Ronald plans to conduct a research on the use of b. Compliance to expected standards first?
person who conducted it. Which type of a new method of pain assessment scale. Which c. Level of satisfaction a. Arrange for typing and cross matching of
reference source refers to this? of the following is the second step in the d. Degree of acceptance the client’s blood.
a. Footnote conceptualizing phase of the research process? b. Compare the client’s identification
b. Bibliography a. Formulating the research hypothesis 83. Which of the following theory addresses the four wristband with the tag on the unit of
c. Primary source b. Review related literature modes of adaptation? blood.
d. Endnotes c. Formulating and delimiting the research a. Madeleine Leininger c. Start an I.V. infusion of normal saline
problem b. Sr. Callista Roy solution.
73. When Nurse Trish is providing care to his d. Design the theoretical and conceptual c. Florence Nightingale d. Measure the client’s vital signs.
patient, she must remember that her duty is framework d. Jean Watson
bound not to do doing any action that will cause 90. A 65 years old male client requests his
the patient harm. This is the meaning of the 78. The leader of the study knows that certain 84. Ms. Garcia is responsible to the number of medication at 9 p.m. instead of 10 p.m. so that
bioethical principle: patients who are in a specialized research setting personnel reporting to her. This principle refers he can go to sleep earlier. Which type of nursing
a. Non-maleficence tend to respond psychologically to the to: intervention is required?
b. Beneficence conditions of the study. This referred to as : a. Span of control a. Independent
c. Justice a. Cause and effect b. Unity of command b. Dependent
d. Solidarity b. Hawthorne effect c. Downward communication c. Interdependent
c. Halo effect d. Leader d. Intradependent
74. When a nurse in-charge causes an injury to a d. Horns effect
female patient and the injury caused becomes 85. Ensuring that there is an informed consent on 91. A female client is to be discharged from an acute
the proof of the negligent act, the presence of 79. Mary finally decides to use judgment sampling the part of the patient before a surgery is done, care facility after treatment for right leg
the injury is said to exemplify the principle of: on her research. Which of the following actions illustrates the bioethical principle of: thrombophlebitis. The Nurse Betty notes that
a. Force majeure of is correct? a. Beneficence the client's leg is pain-free, without redness or
b. Respondeat superior a. Plans to include whoever is there during b. Autonomy edema. The nurse's actions reflect which step of
c. Res ipsa loquitor his study. c. Veracity the nursing process?
d. Holdover doctrine b. Determines the different nationality of d. Non-maleficence a. Assessment
patients frequently admitted and b. Diagnosis
75. Nurse Myrna is aware that the Board of Nursing decides to get representations samples 86. Nurse Reese is teaching a female client with c. Implementation
has quasi-judicial power. An example of this from each. peripheral vascular disease about foot care; d. Evaluation
power is: c. Assigns numbers for each of the Nurse Reese should include which instruction?
a. The Board can issue rules and patients, place these in a fishbowl and a. Avoid wearing cotton socks. 92. Nursing care for a female client includes
regulations that will govern the practice draw 10 from it. b. Avoid using a nail clipper to cut toenails. removing elastic stockings once per day. The
of nursing d. Decides to get 20 samples from the c. Avoid wearing canvas shoes. Nurse Betty is aware that the rationale for this
b. The Board can investigate violations of admitted patients d. Avoid using cornstarch on feet. intervention?
the nursing law and code of ethics a. To increase blood flow to the heart
c. The Board can visit a school applying for 80. The nursing theorist who developed 87. A client is admitted with multiple pressure b. To observe the lower extremities
a permit in collaboration with CHED transcultural nursing theory is: ulcers. When developing the client's diet plan, c. To allow the leg muscles to stretch and
d. The Board prepares the board a. Florence Nightingale the nurse should include: relax
examinations b. Madeleine Leininger a. Fresh orange slices d. To permit veins in the legs to fill with
c. Albert Moore b. Steamed broccoli blood.
76. When the license of nurse Krina is revoked, it d. Sr. Callista Roy c. Ice cream
means that she: d. Ground beef patties 93. Which nursing intervention takes highest priority
a. Is no longer allowed to practice the 81. Marion is aware that the sampling method that when caring for a newly admitted client who's
profession for the rest of her life gives equal chance to all units in the population 88. The nurse prepares to administer a cleansing receiving a blood transfusion?
b. Will never have her/his license re-issued to get picked is: enema. What is the most common client a. Instructing the client to report any
since it has been revoked a. Random position used for this procedure? itching, swelling, or dyspnea.
c. May apply for re-issuance of his/her b. Accidental a. Lithotomy b. Informing the client that the transfusion
license based on certain conditions c. Quota b. Supine usually take 1 ½ to 2 hours.
stipulated in RA 9173 d. Judgment c. Prone c. Documenting blood administration in
d. Sims’ left lateral the client care record.
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d. Assessing the client’s vital signs when d. 30 minutes after administering the next Rationale: Curling’s ulcer occurs as a
the transfusion ends. dose. generalized stress response in burn patients.
Answers and Rationale – Foundation of This results in a decreased production of
94. A male client complains of abdominal discomfort 99. Nurse May is aware that the main advantage of Professional Nursing Practice mucus and increased secretion of gastric acid.
and nausea while receiving tube feedings. Which using a floor stock system is: The best treatment for this prophylactic use of
intervention is most appropriate for this a. The nurse can implement medication antacids and H2 receptor blockers.
problem? orders quickly. 1. Answer: (D) The actions of a reasonably 8. Answer: (D) Continue to monitor and record
a. Give the feedings at room temperature. b. The nurse receives input from the prudent nurse with similar education and hourly urine output
b. Decrease the rate of feedings and the pharmacist. experience. Rationale: Normal urine output for an adult is
concentration of the formula. c. The system minimizes transcription Rationale: The standard of care is determined approximately 1 ml/minute (60 ml/hour).
c. Place the client in semi-Fowler's position errors. by the average degree of skill, care, and Therefore, this client's output is normal.
while feeding. d. The system reinforces accurate diligence by nurses in similar circumstances. Beyond continued evaluation, no nursing
d. Change the feeding container every 12 calculations. 2. Answer: (B) I.M action is warranted.
hours. Rationale: With a platelet count of 22,000/μl, 9. Answer: (B) “My ankle feels warm”.
100. Nurse Oliver is assessing a client's abdomen. the clients tends to bleed easily. Therefore, Rationale: Ice application decreases pain and
95. Nurse Patricia is reconstituting a powdered Which finding should the nurse report as the nurse should avoid using the I.M. route swelling. Continued or increased pain, redness,
medication in a vial. After adding the solution to abnormal? because the area is a highly vascular and can and increased warmth are signs of
the powder, she nurse should: a. Dullness over the liver. bleed readily when penetrated by a needle. inflammation that shouldn't occur after ice
a. Do nothing. b. Bowel sounds occurring every 10 The bleeding can be difficult to stop. application
b. Invert the vial and let it stand for 3 to 5 seconds. 3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” 10. Answer: (B) Hyperkalemia
minutes. c. Shifting dullness over the abdomen. Rationale: The nurse should always place a Rationale: A loop diuretic removes water and,
c. Shake the vial vigorously. d. Vascular sounds heard over the renal zero before a decimal point so that no one along with it, sodium and potassium. This may
d. Roll the vial gently between the palms. arteries. misreads the figure, which could result in a result in hypokalemia, hypovolemia, and
dosage error. The nurse should never insert a hyponatremia.
96. Which intervention should the nurse Trish use zero at the end of a dosage that includes a 11. Answer:(A) Have condescending trust and
when administering oxygen by face mask to a decimal point because this could be misread, confidence in their subordinates
female client? possibly leading to a tenfold increase in the Rationale: Benevolent-authoritative managers
a. Secure the elastic band tightly around dosage. pretentiously show their trust and confidence
the client's head. 4. Answer: (A) Ineffective peripheral tissue to their followers.
b. Assist the client to the semi-Fowler perfusion related to venous congestion. 12. Answer: (A) Provides continuous, coordinated
position if possible. Rationale: Ineffective peripheral tissue and comprehensive nursing services.
c. Apply the face mask from the client's perfusion related to venous congestion takes Rationale: Functional nursing is focused on
chin up over the nose. the highest priority because venous tasks and activities and not on the care of the
d. Loosen the connectors between the inflammation and clot formation impede blood patients.
oxygen equipment and humidifier. flow in a client with deep vein thrombosis. 13. Answer: (B) Standard written order
5. Answer: (B) A 44 year-old myocardial Rationale: This is a standard written order.
97. The maximum transfusion time for a unit of infarction (MI) client who is complaining of Prescribers write a single order for
packed red blood cells (RBCs) is: nausea. medications given only once. A stat order is
a. 6 hours Rationale: Nausea is a symptom of impending written for medications given immediately for
b. 4 hours myocardial infarction (MI) and should be an urgent client problem. A standing order,
c. 3 hours assessed immediately so that treatment can also known as a protocol, establishes
d. 2 hours be instituted and further damage to the heart guidelines for treating a particular disease or
is avoided. set of symptoms in special care areas such as
98. Nurse Monique is monitoring the effectiveness 6. Answer: (C) Check circulation every 15-30 the coronary care unit. Facilities also may
of a client's drug therapy. When should the minutes. institute medication protocols that specifically
nurse Monique obtain a blood sample to Rationale: Restraints encircle the limbs, which designate drugs that a nurse may not give.
measure the trough drug level? place the client at risk for circulation being 14. Answer: (D) Liquid or semi-liquid stools
a. 1 hour before administering the next restricted to the distal areas of the Rationale: Passage of liquid or semi-liquid
dose. extremities. Checking the client’s circulation stools results from seepage of unformed
b. Immediately before administering the every 15-30 minutes will allow the nurse to bowel contents around the impacted stool in
next dose. adjust the restraints before injury from the rectum. Clients with fecal impaction don't
c. Immediately after administering the decreased blood flow occurs. pass hard, brown, formed stools because the
next dose. 7. Answer: (A) Prevent stress ulcer feces can't move past the impaction. These
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clients typically report the urge to defecate Rationale: The client who has a radiation Rationale: Evaluation includes observing the Rationale: Failing eyesight, especially close
(although they can't pass stool) and a implant is placed in a private room and has a person, asking questions, and comparing the vision, is one of the first signs of aging in
decreased appetite. limited number of visitors. This reduces the patient’s behavioral responses with the middle life (ages 46 to 64). More frequent
15. Answer: (C) Pulling the helix up and back exposure of others to the radiation. expected outcomes. aches and pains begin in the early late years
Rationale: To perform an otoscopic 23. Answer: (C) Risk for infection 32. Answer: (C) History of present illness (ages 65 to 79). Increase in loss of muscle tone
examination on an adult, the nurse grasps the Rationale: Agranulocytosis is characterized by Rationale: The history of present illness is the occurs in later years (age 80 and older).
helix of the ear and pulls it up and back to a reduced number of leukocytes (leucopenia) single most important factor in assisting the 41. Answer: (A) Checking and taping all
straighten the ear canal. For a child, the nurse and neutrophils (neutropenia) in the blood. health professional in arriving at a diagnosis or connections
grasps the helix and pulls it down to straighten The client is at high risk for infection because determining the person’s needs. Rationale: Air leaks commonly occur if the
the ear canal. Pulling the lobule in any of the decreased body defenses against 33. Answer: (A) Trochanter roll extending from the system isn’t secure. Checking all connections
direction wouldn't straighten the ear canal for microorganisms. Deficient knowledge related crest of the ileum to the mid-thigh. and taping them will prevent air leaks. The
visualization. to the nature of the disorder may be Rationale: A trochanter roll, properly placed, chest drainage system is kept lower to
16. Answer: (A) Protect the irritated skin from appropriate diagnosis but is not the priority. provides resistance to the external rotation of promote drainage – not to prevent leaks.
sunlight. 24. Answer: (B) Place the client on the left side in the hip. 42. Answer: (A) Check the client’s identification
Rationale: Irradiated skin is very sensitive and the Trendelenburg position. 34. Answer: (C) Stage III band.
must be protected with clothing or sunblock. Rationale: Lying on the left side may prevent Rationale: Clinically, a deep crater or without Rationale: Checking the client’s identification
The priority approach is the avoidance of air from flowing into the pulmonary veins. The undermining of adjacent tissue is noted. band is the safest way to verify a client’s
strong sunlight. Trendelenburg position increases intrathoracic 35. Answer: (A) Second intention healing identity because the band is assigned on
17. Answer: (C) Assist the client in removing pressure, which decreases the amount of Rationale: When wounds dehisce, they will admission and isn’t be removed at any time. (If
dentures and nail polish. blood pulled into the vena cava during allowed to heal by secondary Intention it is removed, it must be replaced). Asking the
Rationale: Dentures, hairpins, and combs must aspiration. 36. Answer: (D) Tachycardia client’s name or having the client repeated his
be removed. Nail polish must be removed so 25. Answer: (A) Autocratic. Rationale: With an extracellular fluid or plasma name would be appropriate only for a client
that cyanosis can be easily monitored by Rationale: The autocratic style of leadership is volume deficit, compensatory mechanisms who’s alert, oriented, and able to understand
observing the nail beds. a task-oriented and directive. stimulate the heart, causing an increase in what is being said, but isn’t the safe standard
18. Answer: (D) Sudden onset of continuous 26. Answer: (D) 2.5 cc heart rate. of practice. Names on bed aren’t always
epigastric and back pain. Rationale: 2.5 cc is to be added, because only a 37. Answer: (A) 0.75 reliable
Rationale: The autodigestion of tissue by the 500 cc bag of solution is being medicated Rationale: To determine the number of 43. Answer: (B) 32 drops/minute
pancreatic enzymes results in pain from instead of a 1 liter. milliliters the client should receive, the nurse Rationale: Giving 1,000 ml over 8 hours is the
inflammation, edema, and possible 27. Answer: (A) 50 cc/ hour uses the fraction method in the following same as giving 125 ml over 1 hour (60
hemorrhage. Continuous, unrelieved epigastric Rationale: A rate of 50 cc/hr. The child is to equation. minutes). Find the number of milliliters per
or back pain reflects the inflammatory process receive 400 cc over a period of 8 hours = 50 75 mg/X ml = 100 mg/1 ml minute as follows:
in the pancreas. cc/hr. To solve for X, cross-multiply: 125/60 minutes = X/1 minute
19. Answer: (B) Provide high-protein, high- 28. Answer: (B) Assess the client for presence of 75 mg x 1 ml = X ml x 100 mg 60X = 125 = 2.1 ml/minute
carbohydrate diet. pain. 75 = 100X To find the number of drops per minute:
Rationale: A positive nitrogen balance is Rationale: Assessing the client for pain is a 75/100 = X 2.1 ml/X gtt = 1 ml/ 15 gtt
important for meeting metabolic needs, tissue very important measure. Postoperative pain is 0.75 ml (or ¾ ml) = X X = 32 gtt/minute, or 32 drops/minute
repair, and resistance to infection. Caloric an indication of complication. The nurse 38. Answer: (D) it’s a measure of effect, not a 44. Answer: (A) Clamp the catheter
goals may be as high as 5000 calories per day. should also assess the client for pain to standard measure of weight or quantity. Rationale: If a central venous catheter
20. Answer: (A) Blood pressure and pulse rate. provide for the client’s comfort. Rationale: An insulin unit is a measure of becomes disconnected, the nurse should
Rationale: The baseline must be established to 29. Answer: (A) BP – 80/60, Pulse – 110 irregular effect, not a standard measure of weight or immediately apply a catheter clamp, if
recognize the signs of an anaphylactic or Rationale: The classic signs of cardiogenic quantity. Different drugs measured in units available. If a clamp isn’t available, the nurse
hemolytic reaction to the transfusion. shock are low blood pressure, rapid and weak may have no relationship to one another in can place a sterile syringe or catheter plug in
21. Answer: (D) Immobilize the leg before moving irregular pulse, cold, clammy skin, decreased quality or quantity. the catheter hub. After cleaning the hub with
the client. urinary output, and cerebral hypoxia. 39. Answer: (B) 38.9 °C alcohol or povidone-iodine solution, the nurse
Rationale: If the nurse suspects a fracture, 30. Answer: (A) Take the proper equipment, place Rationale: To convert Fahrenheit degreed to must replace the I.V. extension and restart the
splinting the area before moving the client is the client in a comfortable position, and Centigrade, use this formula infusion.
imperative. The nurse should call for record the appropriate information in the °C = (°F – 32) ÷ 1.8 45. Answer: (D) Auscultation, percussion, and
emergency help if the client is not hospitalized client’s chart. °C = (102 – 32) ÷ 1.8 palpation.
and call for a physician for the hospitalized Rationale: It is a general or comprehensive °C = 70 ÷ 1.8 Rationale: The correct order of assessment for
client. statement about the correct procedure, and it °C = 38.9 examining the abdomen is inspection,
22. Answer: (B) Admit the client into a private includes the basic ideas which are found in the 40. Answer: (C) Failing eyesight, especially close auscultation, percussion, and palpation. The
room. other options vision. reason for this approach is that the less
31. Answer: (B) Evaluation intrusive techniques should be performed
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before the more intrusive techniques. interventions and will protect the area. Using a Rationale: A urine specimen is not taken from because of the risk for potential heat loss.
Percussion and palpation can alter natural povidone-iodine wash and an antibiotic cream the urinary drainage bag. Urine undergoes Hurried movements and rapid changes in the
findings during auscultation. require a physician’s order. Massaging with an chemical changes while sitting in the bag and position should be avoided because these
46. Answer: (D) Ulnar surface of the hand astringent can further damage the skin. does not necessarily reflect the current client predispose the client to hypotension. At the
Rationale: The nurse uses the ulnar surface, or 52. Answer: (D) Foot status. In addition, it may become time of the transfer from the surgery table to
ball, of the hand to assess tactile fremitus, Rationale: An elastic bandage should be contaminated with bacteria from opening the the stretcher, the client is still affected by the
thrills, and vocal vibrations through the chest applied form the distal area to the proximal system. effects of the anesthesia; therefore, the client
wall. The fingertips and finger pads best area. This method promotes venous return. In 59. Answer: (B) Cover the client, place the call should not move self. Safety belts can prevent
distinguish texture and shape. The dorsal this case, the nurse should begin applying the light within reach, and answer the phone call. the client from falling off the stretcher.
surface best feels warmth. bandage at the client’s foot. Beginning at the Rationale: Because telephone call is an 64. Answer: (B) Gown and gloves
47. Answer: (C) Formative ankle, lower thigh, or knee does not promote emergency, the nurse may need to answer it. Rationale: Contact precautions require the use
Rationale: Formative (or concurrent) venous return. The other appropriate action is to ask another of gloves and a gown if direct client contact is
evaluation occurs continuously throughout the 53. Answer: (B) Hypokalemia nurse to accept the call. However, is not one of anticipated. Goggles are not necessary unless
teaching and learning process. One benefit is Rationale: Insulin administration causes the options. To maintain privacy and safety, the nurse anticipates the splashes of blood,
that the nurse can adjust teaching strategies glucose and potassium to move into the cells, the nurse covers the client and places the call body fluids, secretions, or excretions may
as necessary to enhance learning. Summative, causing hypokalemia. light within the client’s reach. Additionally, the occur. Shoe protectors are not necessary.
or retrospective, evaluation occurs at the 54. Answer: (A) Throbbing headache or dizziness client’s door should be closed or the room 65. Answer: (C) Quad cane
conclusion of the teaching and learning Rationale: Headache and dizziness often occur curtains pulled around the bathing area. Rationale: Crutches and a walker can be
session. Informative is not a type of when nitroglycerin is taken at the beginning of 60. Answer: (C) Use a sterile plastic container for difficult to maneuver for a client with
evaluation. therapy. However, the client usually develops obtaining the specimen. weakness on one side. A cane is better suited
48. Answer: (B) Once per year tolerance Rationale: Sputum specimens for culture and for client with weakness of the arm and leg on
Rationale: Yearly mammograms should begin 55. Answer: (D) Check the client’s level of sensitivity testing need to be obtained using one side. However, the quad cane would
at age 40 and continue for as long as the consciousness sterile techniques because the test is done to provide the most stability because of the
woman is in good health. If health risks, such Rationale: Determining unresponsiveness is determine the presence of organisms. If the structure of the cane and because a quad cane
as family history, genetic tendency, or past the first step assessment action to take. When procedure for obtaining the specimen is not has four legs.
breast cancer, exist, more frequent a client is in ventricular tachycardia, there is a sterile, then the specimen is not sterile, then 66. Answer: (D) Left side-lying with the head of
examinations may be necessary. significant decrease in cardiac output. the specimen would be contaminated and the the bed elevated 45 degrees.
49. Answer: (A) Respiratory acidosis However, checking the unresponsiveness results of the test would be invalid. Rationale: To facilitate removal of fluid from
Rationale: The client has a below-normal ensures whether the client is affected by the 61. Answer: (A) Puts all the four points of the the chest wall, the client is positioned sitting at
(acidic) blood pH value and an above-normal decreased cardiac output. walker flat on the floor, puts weight on the the edge of the bed leaning over the bedside
partial pressure of arterial carbon dioxide 56. Answer: (B) On the affected side of the client. hand pieces, and then walks into it. table with the feet supported on a stool. If the
(Paco2) value, indicating respiratory acidosis. Rationale: When walking with clients, the Rationale: When the client uses a walker, the client is unable to sit up, the client is
In respiratory alkalosis, the pH value is above nurse should stand on the affected side and nurse stands adjacent to the affected side. The positioned lying in bed on the unaffected side
normal and in the Paco2 value is below grasp the security belt in the midspine area of client is instructed to put all four points of the with the head of the bed elevated 30 to 45
normal. In metabolic acidosis, the pH and the small of the back. The nurse should walker 2 feet forward flat on the floor before degrees.
bicarbonate (Hco3) values are below normal. position the free hand at the shoulder area so putting weight on hand pieces. This will ensure 67. Answer: (D) Reliability
In metabolic alkalosis, the pH and Hco3 values that the client can be pulled toward the nurse client safety and prevent stress cracks in the Rationale: Reliability is consistency of the
are above normal. in the event that there is a forward fall. The walker. The client is then instructed to move research instrument. It refers to the
50. Answer: (B) To provide support for the client client is instructed to look up and outward the walker forward and walk into it. repeatability of the instrument in extracting
and family in coping with terminal illness. rather than at his or her feet. 62. Answer: (C) Draws one line to cross out the the same responses upon its repeated
Rationale: Hospices provide supportive care 57. Answer: (A) Urine output: 45 ml/hr incorrect information and then initials the administration.
for terminally ill clients and their families. Rationale: Adequate perfusion must be change. 68. Answer: (A) Keep the identities of the subject
Hospice care doesn’t focus on counseling maintained to all vital organs in order for the Rationale: To correct an error documented in a secret
regarding health care costs. Most client client to remain visible as an organ donor. A medical record, the nurse draws one line Rationale: Keeping the identities of the
referred to hospices have been treated for urine output of 45 ml per hour indicates through the incorrect information and then research subject secret will ensure anonymity
their disease without success and will receive adequate renal perfusion. Low blood pressure initials the error. An error is never erased and because this will hinder providing link between
only palliative care in the hospice. and delayed capillary refill time are circulatory correction fluid is never used in the medical the information given to whoever is its source.
51. Answer: (C) Using normal saline solution to system indicators of inadequate perfusion. A record. 69. Answer: (A) Descriptive- correlational
clean the ulcer and applying a protective serum pH of 7.32 is acidotic, which adversely 63. Answer: (C) Secures the client safety belts Rationale: Descriptive- correlational study is
dressing as necessary. affects all body tissues. after transferring to the stretcher. the most appropriate for this study because it
Rationale: Washing the area with normal 58. Answer: (D ) Obtaining the specimen from the Rationale: During the transfer of the client studies the variables that could be the
saline solution and applying a protective urinary drainage bag. after the surgical procedure is complete, the antecedents of the increased incidence of
dressing are within the nurse’s realm of nurse should avoid exposure of the client nosocomial infection.
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70. Answer: (C) Use of laboratory data working conditions of the workers on their The client should be instructed to cut toenails nursing process where the nurse puts the plan
Rationale: Incidence of nosocomial infection is productivity. It resulted to an increased straight across with nail clippers. of care into action.
best collected through the use of productivity but not due to the intervention 87. Answer: (D) Ground beef patties 92. Answer: (B) To observe the lower extremities
biophysiologic measures, particularly in vitro but due to the psychological effects of being Rationale: Meat is an excellent source of Rationale: Elastic stockings are used to
measurements, hence laboratory data is observed. They performed differently because complete protein, which this client needs to promote venous return. The nurse needs to
essential. they were under observation. repair the tissue breakdown caused by remove them once per day to observe the
71. Answer: (B) Quasi-experiment 79. Answer: (B) Determines the different pressure ulcers. Oranges and broccoli supply condition of the skin underneath the stockings.
Rationale: Quasi-experiment is done when nationality of patients frequently admitted and vitamin C but not protein. Ice cream supplies Applying the stockings increases blood flow to
randomization and control of the variables are decides to get representations samples from only some incomplete protein, making it less the heart. When the stockings are in place, the
not possible. each. helpful in tissue repair. leg muscles can still stretch and relax, and the
72. Answer: (C) Primary source Rationale: Judgment sampling involves 88. Answer: (D) Sims’ left lateral veins can fill with blood.
Rationale: This refers to a primary source including samples according to the knowledge Rationale: The Sims' left lateral position is the 93. Answer :(A) Instructing the client to report any
which is a direct account of the investigation of the investigator about the participants in most common position used to administer a itching, swelling, or dyspnea.
done by the investigator. In contrast to this is a the study. cleansing enema because it allows gravity to Rationale: Because administration of blood or
secondary source, which is written by 80. Answer: (B) Madeleine Leininger aid the flow of fluid along the curve of the blood products may cause serious adverse
someone other than the original researcher. Rationale: Madeleine Leininger developed the sigmoid colon. If the client can't assume this effects such as allergic reactions, the nurse
73. Answer: (A) Non-maleficence theory on transcultural theory based on her position nor has poor sphincter control, the must monitor the client for these effects. Signs
Rationale: Non-maleficence means do not observations on the behavior of selected dorsal recumbent or right lateral position may and symptoms of life-threatening allergic
cause harm or do any action that will cause people within a culture. be used. The supine and prone positions are reactions include itching, swelling, and
any harm to the patient/client. To do good is 81. Answer: (A) Random inappropriate and uncomfortable for the dyspnea. Although the nurse should inform
referred as beneficence. Rationale: Random sampling gives equal client. the client of the duration of the transfusion
74. Answer: (C) Res ipsa loquitor chance for all the elements in the population 89. Answer: (A) Arrange for typing and cross and should document its administration, these
Rationale: Res ipsa loquitor literally means the to be picked as part of the sample. matching of the client’s blood. actions are less critical to the client's
thing speaks for itself. This means in 82. Answer: (A) Degree of agreement and Rationale: The nurse first arranges for typing immediate health. The nurse should assess
operational terms that the injury caused is the disagreement and cross matching of the client's blood to vital signs at least hourly during the
proof that there was a negligent act. Rationale: Likert scale is a 5-point summated ensure compatibility with donor blood. The transfusion.
75. Answer: (B) The Board can investigate scale used to determine the degree of other options, although appropriate when 94. Answer: (B) Decrease the rate of feedings and
violations of the nursing law and code of ethics agreement or disagreement of the preparing to administer a blood transfusion, the concentration of the formula.
Rationale: Quasi-judicial power means that the respondents to a statement in a study come later. Rationale: Complaints of abdominal
Board of Nursing has the authority to 83. Answer: (B) Sr. Callista Roy 90. Answer: (A) Independent discomfort and nausea are common in clients
investigate violations of the nursing law and Rationale: Sr. Callista Roy developed the Rationale: Nursing interventions are classified receiving tube feedings. Decreasing the rate of
can issue summons, subpoena or subpoena Adaptation Model which involves the as independent, interdependent, or the feeding and the concentration of the
duces tecum as needed. physiologic mode, self-concept mode, role dependent. Altering the drug schedule to formula should decrease the client's
76. Answer: (C) May apply for re-issuance of function mode and dependence mode. coincide with the client's daily routine discomfort. Feedings are normally given at
his/her license based on certain conditions 84. Answer: (A) Span of control represents an independent intervention, room temperature to minimize abdominal
stipulated in RA 9173 Rationale: Span of control refers to the whereas consulting with the physician and cramping. To prevent aspiration during
Rationale: RA 9173 sec. 24 states that for number of workers who report directly to a pharmacist to change a client's medication feeding, the head of the client's bed should be
equity and justice, a revoked license maybe re- manager. because of adverse reactions represents an elevated at least 30 degrees. Also, to prevent
issued provided that the following conditions 85. Answer: (B) Autonomy interdependent intervention. Administering an bacterial growth, feeding containers should be
are met: a) the cause for revocation of license Rationale: Informed consent means that the already-prescribed drug on time is a routinely changed every 8 to 12 hours.
has already been corrected or removed; and, patient fully understands about the surgery, dependent intervention. An intradependent 95. Answer: (D) Roll the vial gently between the
b) at least four years has elapsed since the including the risks involved and the alternative nursing intervention doesn't exist. palms.
license has been revoked. solutions. In giving consent it is done with full 91. Answer: (D) Evaluation Rationale: Rolling the vial gently between the
77. Answer: (B) Review related literature knowledge and is given freely. The action of Rationale: The nursing actions described palms produces heat, which helps dissolve the
Rationale: After formulating and delimiting the allowing the patient to decide whether a constitute evaluation of the expected medication. Doing nothing or inverting the vial
research problem, the researcher conducts a surgery is to be done or not exemplifies the outcomes. The findings show that the wouldn't help dissolve the medication. Shaking
review of related literature to determine the bioethical principle of autonomy. expected outcomes have been achieved. the vial vigorously could cause the medication
extent of what has been done on the study by 86. Answer: (C) Avoid wearing canvas shoes. Assessment consists of the client's history, to break down, altering its action.
previous researchers. Rationale: The client should be instructed to physical examination, and laboratory studies. 96. Answer: (B) Assist the client to the semi-
78. Answer: (B) Hawthorne effect avoid wearing canvas shoes. Canvas shoes Analysis consists of considering assessment Fowler position if possible.
Rationale: Hawthorne effect is based on the cause the feet to perspire, which may, in turn, information to derive the appropriate nursing Rationale: By assisting the client to the semi-
study of Elton Mayo and company about the cause skin irritation and breakdown. Both diagnosis. Implementation is the phase of the Fowler position, the nurse promotes easier
effect of an intervention done to improve the cotton and cornstarch absorb perspiration. chest expansion, breathing, and oxygen intake.
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The nurse should secure the elastic band so TEST II - Community Health Nursing and Care of the a. Excessive fetal activity.
that the face mask fits comfortably and snugly Mother and Child b. Larger than normal uterus for
rather than tightly, which could lead to gestational age.
irritation. The nurse should apply the face 1. May arrives at the health care clinic and tells the c. Vaginal bleeding
mask from the client's nose down to the chin nurse that her last menstrual period was 9 d. Elevated levels of human chorionic
— not vice versa. The nurse should check the weeks ago. She also tells the nurse that a home gonadotropin.
connectors between the oxygen equipment pregnancy test was positive but she began to
and humidifier to ensure that they're airtight; have mild cramps and is now having moderate 6. A pregnant client is receiving magnesium sulfate
loosened connectors can cause loss of oxygen. vaginal bleeding. During the physical for severe pregnancy induced hypertension
97. Answer: (B) 4 hours examination of the client, the nurse notes that (PIH). The clinical findings that would warrant
Rationale: A unit of packed RBCs may be given May has a dilated cervix. The nurse determines use of the antidote , calcium gluconate is:
over a period of between 1 and 4 hours. It that May is experiencing which type of abortion? a. Urinary output 90 cc in 2 hours.
shouldn't infuse for longer than 4 hours a. Inevitable b. Absent patellar reflexes.
because the risk of contamination and sepsis b. Incomplete c. Rapid respiratory rate above 40/min.
increases after that time. Discard or return to c. Threatened d. Rapid rise in blood pressure.
the blood bank any blood not given within this d. Septic
time, according to facility policy. 7. During vaginal examination of Janah who is in
98. Answer: (B) Immediately before administering 2. Nurse Reese is reviewing the record of a labor, the presenting part is at station plus two.
the next dose. pregnant client for her first prenatal visit. Which Nurse, correctly interprets it as:
Rationale: Measuring the blood drug of the following data, if noted on the client’s a. Presenting part is 2 cm above the plane
concentration helps determine whether the record, would alert the nurse that the client is at of the ischial spines.
dosing has achieved the therapeutic goal. For risk for a spontaneous abortion? b. Biparietal diameter is at the level of the
measurement of the trough, or lowest, blood a. Age 36 years ischial spines.
level of a drug, the nurse draws a blood b. History of syphilis c. Presenting part in 2 cm below the plane
sample immediately before administering the c. History of genital herpes of the ischial spines.
next dose. Depending on the drug's duration d. History of diabetes mellitus d. Biparietal diameter is 2 cm above the
of action and half-life, peak blood drug levels ischial spines.
typically are drawn after administering the 3. Nurse Hazel is preparing to care for a client who
next dose. is newly admitted to the hospital with a possible 8. A pregnant client is receiving oxytocin (Pitocin)
99. Answer: (A) The nurse can implement diagnosis of ectopic pregnancy. Nurse Hazel for induction of labor. A condition that warrant
medication orders quickly. develops a plan of care for the client and the nurse in-charge to discontinue I.V. infusion
Rationale: A floor stock system enables the determines that which of the following nursing of Pitocin is:
nurse to implement medication orders quickly. actions is the priority? a. Contractions every 1 ½ minutes lasting
It doesn't allow for pharmacist input, nor does a. Monitoring weight 70-80 seconds.
it minimize transcription errors or reinforce b. Assessing for edema b. Maternal temperature 101.2
accurate calculations. c. Monitoring apical pulse c. Early decelerations in the fetal heart
100. Answer: (C) Shifting dullness over the d. Monitoring temperature rate.
abdomen. d. Fetal heart rate baseline 140-160 bpm.
Rationale: Shifting dullness over the abdomen 4. Nurse Oliver is teaching a diabetic pregnant
indicates ascites, an abnormal finding. The client about nutrition and insulin needs during 9. Calcium gluconate is being administered to a
other options are normal abdominal findings. pregnancy. The nurse determines that the client client with pregnancy induced hypertension
understands dietary and insulin needs if the (PIH). A nursing action that must be initiated as
client states that the second half of pregnancy the plan of care throughout injection of the drug
requires: is:
a. Decreased caloric intake a. Ventilator assistance
b. Increased caloric intake b. CVP readings
c. Decreased Insulin c. EKG tracings
d. Increase Insulin d. Continuous CPR
5. Nurse Michelle is assessing a 24 year old client 10. A trial for vaginal delivery after an earlier
with a diagnosis of hydatidiform mole. She is caesarean, would likely to be given to a gravida,
aware that one of the following is unassociated who had:
with this condition?
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a. First low transverse cesarean was for infant looks for it. The nurse is aware that 26. The nurse is caring for a primigravid client in the
active herpes type 2 infections; vaginal estimated age of the infant would be: 21. According to Freeman and Heinrich, community labor and delivery area. Which condition would
culture at 39 weeks pregnancy was a. 6 months health nursing is a developmental service. Which place the client at risk for disseminated
positive. b. 4 months of the following best illustrates this statement? intravascular coagulation (DIC)?
b. First and second caesareans were for c. 8 months a. The community health nurse a. Intrauterine fetal death.
cephalopelvic disproportion. d. 10 months continuously develops himself b. Placenta accreta.
c. First caesarean through a classic incision personally and professionally. c. Dysfunctional labor.
as a result of severe fetal distress. 16. Which of the following is the most prominent b. Health education and community d. Premature rupture of the membranes.
d. First low transverse caesarean was for feature of public health nursing? organizing are necessary in providing
breech position. Fetus in this pregnancy a. It involves providing home care to sick community health services. 27. A fullterm client is in labor. Nurse Betty is aware
is in a vertex presentation. people who are not confined in the c. Community health nursing is intended that the fetal heart rate would be:
hospital. primarily for health promotion and a. 80 to 100 beats/minute
11. Nurse Ryan is aware that the best initial b. Services are provided free of charge to prevention and treatment of disease. b. 100 to 120 beats/minute
approach when trying to take a crying toddler’s people within the catchments area. d. The goal of community health nursing is c. 120 to 160 beats/minute
temperature is: c. The public health nurse functions as part to provide nursing services to people in d. 160 to 180 beats/minute
a. Talk to the mother first and then to the of a team providing a public health their own places of residence.
toddler. nursing services. 28. The skin in the diaper area of a 7 month old
b. Bring extra help so it can be done d. Public health nursing focuses on 22. Nurse Tina is aware that the disease declared infant is excoriated and red. Nurse Hazel should
quickly. preventive, not curative, services. through Presidential Proclamation No. 4 as a instruct the mother to:
c. Encourage the mother to hold the child. target for eradication in the Philippines is? a. Change the diaper more often.
d. Ignore the crying and screaming. 17. When the nurse determines whether resources a. Poliomyelitis b. Apply talc powder with diaper changes.
were maximized in implementing Ligtas Tigdas, b. Measles c. Wash the area vigorously with each
12. Baby Tina a 3 month old infant just had a cleft lip she is evaluating c. Rabies diaper change.
and palate repair. What should the nurse do to a. Effectiveness d. Neonatal tetanus d. Decrease the infant’s fluid intake to
prevent trauma to operative site? b. Efficiency decrease saturating diapers.
a. Avoid touching the suture line, even c. Adequacy 23. May knows that the step in community
when cleaning. d. Appropriateness organizing that involves training of potential 29. Nurse Carla knows that the common cardiac
b. Place the baby in prone position. leaders in the community is: anomalies in children with Down Syndrome (tri-
c. Give the baby a pacifier. 18. Vangie is a new B.S.N. graduate. She wants to a. Integration somy 21) is:
d. Place the infant’s arms in soft elbow become a Public Health Nurse. Where should b. Community organization a. Atrial septal defect
restraints. she apply? c. Community study b. Pulmonic stenosis
a. Department of Health d. Core group formation c. Ventricular septal defect
13. Which action should nurse Marian include in the b. Provincial Health Office d. Endocardial cushion defect
care plan for a 2 month old with heart failure? c. Regional Health Office 24. Beth a public health nurse takes an active role in
a. Feed the infant when he cries. d. Rural Health Unit community participation. What is the primary 30. Malou was diagnosed with severe preeclampsia
b. Allow the infant to rest before feeding. goal of community organizing? is now receiving I.V. magnesium sulfate. The
c. Bathe the infant and administer 19. Tony is aware the Chairman of the Municipal a. To educate the people regarding adverse effects associated with magnesium
medications before feeding. Health Board is: community health problems sulfate is:
d. Weigh and bathe the infant before a. Mayor b. To mobilize the people to resolve a. Anemia
feeding. b. Municipal Health Officer community health problems b. Decreased urine output
c. Public Health Nurse c. To maximize the community’s resources c. Hyperreflexia
14. Nurse Hazel is teaching a mother who plans to d. Any qualified physician in dealing with health problems. d. Increased respiratory rate
discontinue breast feeding after 5 months. The d. To maximize the community’s resources
nurse should advise her to include which foods 20. Myra is the public health nurse in a municipality in dealing with health problems. 31. A 23 year old client is having her menstrual
in her infant’s diet? with a total population of about 20,000. There period every 2 weeks that last for 1 week. This
a. Skim milk and baby food. are 3 rural health midwives among the RHU 25. Tertiary prevention is needed in which stage of type of menstrual pattern is bets defined by:
b. Whole milk and baby food. personnel. How many more midwife items will the natural history of disease? a. Menorrhagia
c. Iron-rich formula only. the RHU need? a. Pre-pathogenesis b. Metrorrhagia
d. Iron-rich formula and baby food. a. 1 b. Pathogenesis c. Dyspareunia
b. 2 c. Prodromal d. Amenorrhea
15. Mommy Linda is playing with her infant, who is c. 3 d. Terminal
sitting securely alone on the floor of the clinic. d. The RHU does not need any more
The mother hides a toy behind her back and the midwife item.
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32. Jannah is admitted to the labor and delivery b. Dehydration and diarrhea newborn becomes too cool, the neonate 47. Barangay Pinoy had an outbreak of German
unit. The critical laboratory result for this client c. Bradycardia and hypotension requires: measles. To prevent congenital rubella, what is
would be: d. Petechiae and hematuria a. Less oxygen, and the newborn’s the BEST advice that you can give to women in
a. Oxygen saturation metabolic rate increases. the first trimester of pregnancy in the barangay
b. Iron binding capacity 38. To evaluate a woman’s understanding about the b. More oxygen, and the newborn’s Pinoy?
c. Blood typing use of diaphragm for family planning, Nurse metabolic rate decreases. a. Advise them on the signs of German
d. Serum Calcium Trish asks her to explain how she will use the c. More oxygen, and the newborn’s measles.
appliance. Which response indicates a need for metabolic rate increases. b. Avoid crowded places, such as markets
33. Nurse Gina is aware that the most common further health teaching? d. Less oxygen, and the newborn’s and movie houses.
condition found during the second-trimester of a. “I should check the diaphragm carefully metabolic rate decreases. c. Consult at the health center where
pregnancy is: for holes every time I use it” rubella vaccine may be given.
a. Metabolic alkalosis b. “I may need a different size of 43. Before adding potassium to an infant’s I.V. line, d. Consult a physician who may give them
b. Respiratory acidosis diaphragm if I gain or lose weight more Nurse Ron must be sure to assess whether this rubella immunoglobulin.
c. Mastitis than 20 pounds” infant has:
d. Physiologic anemia c. “The diaphragm must be left in place for a. Stable blood pressure 48. Myrna a public health nurse knows that to
atleast 6 hours after intercourse” b. Patant fontanelles determine possible sources of sexually
34. Nurse Lynette is working in the triage area of an d. “I really need to use the diaphragm and c. Moro’s reflex transmitted infections, the BEST method that
emergency department. She sees that several jelly most during the middle of my d. Voided may be undertaken is:
pediatric clients arrive simultaneously. The client menstrual cycle”. a. Contact tracing
who needs to be treated first is: 44. Nurse Carla should know that the most common b. Community survey
a. A crying 5 year old child with a 39. Hypoxia is a common complication of causative factor of dermatitis in infants and c. Mass screening tests
laceration on his scalp. laryngotracheobronchitis. Nurse Oliver should younger children is: d. Interview of suspects
b. A 4 year old child with a barking coughs frequently assess a child with a. Baby oil
and flushed appearance. laryngotracheobronchitis for: b. Baby lotion 49. A 33-year old female client came for
c. A 3 year old child with Down syndrome a. Drooling c. Laundry detergent consultation at the health center with the chief
who is pale and asleep in his mother’s b. Muffled voice d. Powder with cornstarch complaint of fever for a week. Accompanying
arms. c. Restlessness symptoms were muscle pains and body malaise.
d. A 2 year old infant with stridorous d. Low-grade fever 45. During tube feeding, how far above an infant’s A week after the start of fever, the client noted
breath sounds, sitting up in his mother’s stomach should the nurse hold the syringe with yellowish discoloration of his sclera. History
arms and drooling. 40. How should Nurse Michelle guide a child who is formula? showed that he waded in flood waters about 2
blind to walk to the playroom? a. 6 inches weeks before the onset of symptoms. Based on
35. Maureen in her third trimester arrives at the a. Without touching the child, talk b. 12 inches her history, which disease condition will you
emergency room with painless vaginal bleeding. continuously as the child walks down the c. 18 inches suspect?
Which of the following conditions is suspected? hall. d. 24 inches a. Hepatitis A
a. Placenta previa b. Walk one step ahead, with the child’s b. Hepatitis B
b. Abruptio placentae hand on the nurse’s elbow. 46. In a mothers’ class, Nurse Lhynnete discussed c. Tetanus
c. Premature labor c. Walk slightly behind, gently guiding the childhood diseases such as chicken pox. Which d. Leptospirosis
d. Sexually transmitted disease child forward. of the following statements about chicken pox is
d. Walk next to the child, holding the correct? 50. Mickey a 3-year old client was brought to the
36. A young child named Richard is suspected of child’s hand. a. The older one gets, the more susceptible health center with the chief complaint of severe
having pinworms. The community nurse collects he becomes to the complications of diarrhea and the passage of “rice water” stools.
a stool specimen to confirm the diagnosis. The 41. When assessing a newborn diagnosed with chicken pox. The client is most probably suffering from which
nurse should schedule the collection of this ductus arteriosus, Nurse Olivia should expect b. A single attack of chicken pox will condition?
specimen for: that the child most likely would have an: prevent future episodes, including a. Giardiasis
a. Just before bedtime a. Loud, machinery-like murmur. conditions such as shingles. b. Cholera
b. After the child has been bathe b. Bluish color to the lips. c. To prevent an outbreak in the c. Amebiasis
c. Any time during the day c. Decreased BP reading in the upper community, quarantine may be imposed d. Dysentery
d. Early in the morning extremities by health authorities.
d. Increased BP reading in the upper d. Chicken pox vaccine is best given when 51. The most prevalent form of meningitis among
37. In doing a child’s admission assessment, Nurse extremities. there is an impending outbreak in the children aged 2 months to 3 years is caused by
Betty should be alert to note which signs or community. which microorganism?
symptoms of chronic lead poisoning? 42. The reason nurse May keeps the neonate in a a. Hemophilus influenzae
a. Irritability and seizures neutral thermal environment is that when a b. Morbillivirus
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c. Steptococcus pneumoniae d. Use of protective footwear, such as 63. Gina is using Oresol in the management of 68. The nurse explains to a breastfeeding mother
d. Neisseria meningitidis rubber boots diarrhea of her 3-year old child. She asked you that breast milk is sufficient for all of the baby’s
what to do if her child vomits. As a nurse you will nutrient needs only up to:
52. The student nurse is aware that the 58. Several clients is newly admitted and diagnosed tell her to: a. 5 months
pathognomonic sign of measles is Koplik’s spot with leprosy. Which of the following clients a. Bring the child to the nearest hospital b. 6 months
and you may see Koplik’s spot by inspecting the: should be classified as a case of multibacillary for further assessment. c. 1 year
a. Nasal mucosa leprosy? b. Bring the child to the health center for d. 2 years
b. Buccal mucosa a. 3 skin lesions, negative slit skin smear intravenous fluid therapy.
c. Skin on the abdomen b. 3 skin lesions, positive slit skin smear c. Bring the child to the health center for 69. Nurse Ron is aware that the gestational age of a
d. Skin on neck c. 5 skin lesions, negative slit skin smear assessment by the physician. conceptus that is considered viable (able to live
d. 5 skin lesions, positive slit skin smear d. Let the child rest for 10 minutes then outside the womb) is:
53. Angel was diagnosed as having Dengue fever. continue giving Oresol more slowly. a. 8 weeks
You will say that there is slow capillary refill 59. Nurses are aware that diagnosis of leprosy is b. 12 weeks
when the color of the nailbed that you pressed highly dependent on recognition of symptoms. 64. Nikki a 5-month old infant was brought by his c. 24 weeks
does not return within how many seconds? Which of the following is an early sign of mother to the health center because of diarrhea d. 32 weeks
a. 3 seconds leprosy? for 4 to 5 times a day. Her skin goes back slowly
b. 6 seconds a. Macular lesions after a skin pinch and her eyes are sunken. Using 70. When teaching parents of a neonate the proper
c. 9 seconds b. Inability to close eyelids the IMCI guidelines, you will classify this infant in position for the neonate’s sleep, the nurse
d. 10 seconds c. Thickened painful nerves which category? Patricia stresses the importance of placing the
d. Sinking of the nosebridge a. No signs of dehydration neonate on his back to reduce the risk of which
54. In Integrated Management of Childhood Illness, b. Some dehydration of the following?
the nurse is aware that the severe conditions 60. Marie brought her 10 month old infant for c. Severe dehydration a. Aspiration
generally require urgent referral to a hospital. consultation because of fever, started 4 days d. The data is insufficient. b. Sudden infant death syndrome (SIDS)
Which of the following severe conditions DOES prior to consultation. In determining malaria c. Suffocation
NOT always require urgent referral to a hospital? risk, what will you do? 65. Chris a 4-month old infant was brought by her d. Gastroesophageal reflux (GER)
a. Mastoiditis a. Perform a tourniquet test. mother to the health center because of cough.
b. Severe dehydration b. Ask where the family resides. His respiratory rate is 42/minute. Using the 71. Which finding might be seen in baby James a
c. Severe pneumonia c. Get a specimen for blood smear. Integrated Management of Child Illness (IMCI) neonate suspected of having an infection?
d. Severe febrile disease d. Ask if the fever is present every day. guidelines of assessment, his breathing is a. Flushed cheeks
considered as: b. Increased temperature
55. Myrna a public health nurse will conduct 61. Susie brought her 4 years old daughter to the a. Fast c. Decreased temperature
outreach immunization in a barangay Masay RHU because of cough and colds. Following the b. Slow d. Increased activity level
with a population of about 1500. The estimated IMCI assessment guide, which of the following is c. Normal
number of infants in the barangay would be: a danger sign that indicates the need for urgent d. Insignificant 72. Baby Jenny who is small-for-gestation is at
a. 45 infants referral to a hospital? increased risk during the transitional period for
b. 50 infants a. Inability to drink 66. Maylene had just received her 4th dose of which complication?
c. 55 infants b. High grade fever tetanus toxoid. She is aware that her baby will a. Anemia probably due to chronic fetal
d. 65 infants c. Signs of severe dehydration have protection against tetanus for hyposia
d. Cough for more than 30 days a. 1 year b. Hyperthermia due to decreased
56. The community nurse is aware that the b. 3 years glycogen stores
biological used in Expanded Program on 62. Jimmy a 2-year old child revealed “baggy pants”. c. 5 years c. Hyperglycemia due to decreased
Immunization (EPI) should NOT be stored in the As a nurse, using the IMCI guidelines, how will d. Lifetime glycogen stores
freezer? you manage Jimmy? d. Polycythemia probably due to chronic
a. DPT a. Refer the child urgently to a hospital for 67. Nurse Ron is aware that unused BCG should be fetal hypoxia
b. Oral polio vaccine confinement. discarded after how many hours of
c. Measles vaccine b. Coordinate with the social worker to reconstitution? 73. Marjorie has just given birth at 42 weeks’
d. MMR enroll the child in a feeding program. a. 2 hours gestation. When the nurse assessing the
c. Make a teaching plan for the mother, b. 4 hours neonate, which physical finding is expected?
57. It is the most effective way of controlling focusing on menu planning for her child. c. 8 hours a. A sleepy, lethargic baby
schistosomiasis in an endemic area? d. Assess and treat the child for health d. At the end of the day b. Lanugo covering the body
a. Use of molluscicides problems like infections and intestinal c. Desquamation of the epidermis
b. Building of foot bridges parasitism. d. Vernix caseosa covering the body
c. Proper use of sanitary toilets
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74. After reviewing the Myrna’s maternal history of b. The parent’s expression of interest successfully resuscitated. Within several hours c. Decreased inspiratory capacity
magnesium sulfate during labor, which condition about the size of the new born. she develops respiratory grunting, cyanosis, d. Decreased oxygen consumption
would nurse Richard anticipate as a potential c. The parents’ indication that they want to tachypnea, nasal flaring, and retractions. She's
problem in the neonate? see the newborn. diagnosed with respiratory distress syndrome, 90. Emily has gestational diabetes and it is usually
a. Hypoglycemia d. The parents’ interactions with each intubated, and placed on a ventilator. Which managed by which of the following therapy?
b. Jitteriness other. nursing action should be included in the baby's a. Diet
c. Respiratory depression plan of care to prevent retinopathy of b. Long-acting insulin
d. Tachycardia 80. Following a precipitous delivery, examination of prematurity? c. Oral hypoglycemic
the client's vagina reveals a fourth-degree a. Cover his eyes while receiving oxygen. d. Oral hypoglycemic drug and insulin
75. Which symptom would indicate the Baby laceration. Which of the following would be b. Keep her body temperature low.
Alexandra was adapting appropriately to extra- contraindicated when caring for this client? c. Monitor partial pressure of oxygen 91. Magnesium sulfate is given to Jemma with
uterine life without difficulty? a. Applying cold to limit edema during the (Pao2) levels. preeclampsia to prevent which of the following
a. Nasal flaring first 12 to 24 hours. d. Humidify the oxygen. condition?
b. Light audible grunting b. Instructing the client to use two or more a. Hemorrhage
c. Respiratory rate 40 to 60 peripads to cushion the area. 85. Which of the following is normal newborn b. Hypertension
breaths/minute c. Instructing the client on the use of sitz calorie intake? c. Hypomagnesemia
d. Respiratory rate 60 to 80 baths if ordered. a. 110 to 130 calories per kg. d. Seizure
breaths/minute d. Instructing the client about the b. 30 to 40 calories per lb of body weight.
importance of perineal (kegel) exercises. c. At least 2 ml per feeding 92. Cammile with sickle cell anemia has an increased
76. When teaching umbilical cord care for Jennifer a d. 90 to 100 calories per kg risk for having a sickle cell crisis during
new mother, the nurse Jenny would include 81. A pregnant woman accompanied by her pregnancy. Aggressive management of a sickle
which information? husband, seeks admission to the labor and 86. Nurse John is knowledgeable that usually cell crisis includes which of the following
a. Apply peroxide to the cord with each delivery area. She states that she's in labor and individual twins will grow appropriately and at measures?
diaper change says she attended the facility clinic for prenatal the same rate as singletons until how many a. Antihypertensive agents
b. Cover the cord with petroleum jelly after care. Which question should the nurse Oliver ask weeks? b. Diuretic agents
bathing her first? a. 16 to 18 weeks c. I.V. fluids
c. Keep the cord dry and open to air a. “Do you have any chronic illnesses?” b. 18 to 22 weeks d. Acetaminophen (Tylenol) for pain
d. Wash the cord with soap and water each b. “Do you have any allergies?” c. 30 to 32 weeks
day during a tub bath. c. “What is your expected due date?” d. 38 to 40 weeks 93. Which of the following drugs is the antidote for
d. “Who will be with you during labor?” magnesium toxicity?
77. Nurse John is performing an assessment on a 87. Which of the following classifications applies to a. Calcium gluconate (Kalcinate)
neonate. Which of the following findings is 82. A neonate begins to gag and turns a dusky color. monozygotic twins for whom the cleavage of the b. Hydralazine (Apresoline)
considered common in the healthy neonate? What should the nurse do first? fertilized ovum occurs more than 13 days after c. Naloxone (Narcan)
a. Simian crease a. Calm the neonate. fertilization? d. Rho (D) immune globulin (RhoGAM)
b. Conjunctival hemorrhage b. Notify the physician. a. conjoined twins
c. Cystic hygroma c. Provide oxygen via face mask as ordered b. diamniotic dichorionic twins 94. Marlyn is screened for tuberculosis during her
d. Bulging fontanelle d. Aspirate the neonate’s nose and mouth c. diamniotic monochorionic twin first prenatal visit. An intradermal injection of
with a bulb syringe. d. monoamniotic monochorionic twins purified protein derivative (PPD) of the
78. Dr. Esteves decides to artificially rupture the tuberculin bacilli is given. She is considered to
membranes of a mother who is on labor. 83. When a client states that her "water broke," 88. Tyra experienced painless vaginal bleeding has have a positive test for which of the following
Following this procedure, the nurse Hazel checks which of the following actions would be just been diagnosed as having a placenta previa. results?
the fetal heart tones for which the following inappropriate for the nurse to do? Which of the following procedures is usually a. An indurated wheal under 10 mm in
reasons? a. Observing the pooling of straw-colored performed to diagnose placenta previa? diameter appears in 6 to 12 hours.
a. To determine fetal well-being. fluid. a. Amniocentesis b. An indurated wheal over 10 mm in
b. To assess for prolapsed cord b. Checking vaginal discharge with nitrazine b. Digital or speculum examination diameter appears in 48 to 72 hours.
c. To assess fetal position paper. c. External fetal monitoring c. A flat circumcised area under 10 mm in
d. To prepare for an imminent delivery. c. Conducting a bedside ultrasound for an d. Ultrasound diameter appears in 6 to 12 hours.
79. Which of the following would be least likely to amniotic fluid index. d. A flat circumcised area over 10 mm in
indicate anticipated bonding behaviors by new d. Observing for flakes of vernix in the 89. Nurse Arnold knows that the following changes diameter appears in 48 to 72 hours.
parents? vaginal discharge. in respiratory functioning during pregnancy is
a. The parents’ willingness to touch and considered normal: 95. Dianne, 24 year-old is 27 weeks’ pregnant
hold the new born. 84. A baby girl is born 8 weeks premature. At birth, a. Increased tidal volume arrives at her physician’s office with complaints
she has no spontaneous respirations but is b. Increased expiratory volume of fever, nausea, vomiting, malaise, unilateral
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flank pain, and costovertebral angle tenderness. a. Uterine inversion hyperstimulation of the uterus, which could
Which of the following diagnoses is most likely? b. Uterine atony result in injury to the mother and the fetus if
a. Asymptomatic bacteriuria c. Uterine involution Answers and Rationale – Community Health Pitocin is not discontinued.
b. Bacterial vaginosis d. Uterine discomfort Nursing and Care of the Mother and Child 9. Answer: (C) EKG tracings
c. Pyelonephritis Rationale: A potential side effect of calcium
d. Urinary tract infection (UTI) 1. Answer: (A) Inevitable gluconate administration is cardiac arrest.
Rationale: An inevitable abortion is termination Continuous monitoring of cardiac activity (EKG)
96. Rh isoimmunization in a pregnant client of pregnancy that cannot be prevented. throught administration of calcium gluconate is
develops during which of the following Moderate to severe bleeding with mild an essential part of care.
conditions? cramping and cervical dilation would be noted 10. Answer: (D) First low transverse caesarean was
a. Rh-positive maternal blood crosses into in this type of abortion. for breech position. Fetus in this pregnancy is in
fetal blood, stimulating fetal antibodies. 2. Answer: (B) History of syphilis a vertex presentation.
b. Rh-positive fetal blood crosses into Rationale: Maternal infections such as syphilis, Rationale: This type of client has no obstetrical
maternal blood, stimulating maternal toxoplasmosis, and rubella are causes of indication for a caesarean section as she did
antibodies. spontaneous abortion. with her first caesarean delivery.
c. Rh-negative fetal blood crosses into 3. Answer: (C) Monitoring apical pulse 11. Answer: (A) Talk to the mother first and then to
maternal blood, stimulating maternal Rationale: Nursing care for the client with a the toddler.
antibodies. possible ectopic pregnancy is focused on Rationale: When dealing with a crying toddler,
d. Rh-negative maternal blood crosses into preventing or identifying hypovolemic shock the best approach is to talk to the mother and
fetal blood, stimulating fetal antibodies. and controlling pain. An elevated pulse rate is ignore the toddler first. This approach helps the
an indicator of shock. toddler get used to the nurse before she
97. To promote comfort during labor, the nurse John 4. Answer: (B) Increased caloric intake attempts any procedures. It also gives the
advises a client to assume certain positions and Rationale: Glucose crosses the placenta, but toddler an opportunity to see that the mother
avoid others. Which position may cause insulin does not. High fetal demands for trusts the nurse.
maternal hypotension and fetal hypoxia? glucose, combined with the insulin resistance 12. Answer: (D) Place the infant’s arms in soft
a. Lateral position caused by hormonal changes in the last half of elbow restraints.
b. Squatting position pregnancy can result in elevation of maternal Rationale: Soft restraints from the upper arm to
c. Supine position blood glucose levels. This increases the the wrist prevent the infant from touching her
d. Standing position mother’s demand for insulin and is referred to lip but allow him to hold a favorite item such as
as the diabetogenic effect of pregnancy. a blanket. Because they could damage the
98. Celeste who used heroin during her pregnancy 5. Answer: (A) Excessive fetal activity. operative site, such as objects as pacifiers,
delivers a neonate. When assessing the neonate, Rationale: The most common signs and suction catheters, and small spoons shouldn’t
the nurse Lhynnette expects to find: symptoms of hydatidiform mole includes be placed in a baby’s mouth after cleft repair. A
a. Lethargy 2 days after birth. elevated levels of human chorionic baby in a prone position may rub her face on
b. Irritability and poor sucking. gonadotropin, vaginal bleeding, larger than the sheets and traumatize the operative site.
c. A flattened nose, small eyes, and thin normal uterus for gestational age, failure to The suture line should be cleaned gently to
lips. detect fetal heart activity even with sensitive prevent infection, which could interfere with
d. Congenital defects such as limb instruments, excessive nausea and vomiting, healing and damage the cosmetic appearance
anomalies. and early development of pregnancy-induced of the repair.
hypertension. Fetal activity would not be noted. 13. Answer: (B) Allow the infant to rest before
99. The uterus returns to the pelvic cavity in which 6. Answer: (B) Absent patellar reflexes feeding.
of the following time frames? Rationale: Absence of patellar reflexes is an Rationale: Because feeding requires so much
a. 7th to 9th day postpartum. indicator of hypermagnesemia, which requires energy, an infant with heart failure should rest
b. 2 weeks postpartum. administration of calcium gluconate. before feeding.
c. End of 6th week postpartum. 7. Answer: (C) Presenting part in 2 cm below the 14. Answer: (C) Iron-rich formula only.
d. When the lochia changes to alba. plane of the ischial spines. Rationale: The infants at age 5 months should
Rationale: Fetus at station plus two indicates receive iron-rich formula and that they
100. Maureen, a primigravida client, age 20, has that the presenting part is 2 cm below the shouldn’t receive solid food, even baby food
just completed a difficult, forceps-assisted plane of the ischial spines. until age 6 months.
delivery of twins. Her labor was unusually 8. Answer: (A) Contractions every 1 ½ minutes 15. Answer: (D) 10 months
long and required oxytocin (Pitocin) lasting 70-80 seconds. Rationale: A 10 month old infant can sit alone
augmentation. The nurse who's caring for her Rationale: Contractions every 1 ½ minutes and understands object permanence, so he
should stay alert for: lasting 70-80 seconds, is indicative of would look for the hidden toy. At age 4 to 6
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months, infants can’t sit securely alone. At age Rationale: Intrauterine fetal death, abruptio Rationale: Based on the nurse’s knowledge of nurse should withhold the potassium and notify
8 months, infants can sit securely alone but placentae, septic shock, and amniotic fluid microbiology, the specimen should be collected the physician.
cannot understand the permanence of objects. embolism may trigger normal clotting early in the morning. The rationale for this 44. Answer: (c) Laundry detergent
16. Answer: (D) Public health nursing focuses on mechanisms; if clotting factors are depleted, timing is that, because the female worm lays Rationale: Eczema or dermatitis is an allergic
preventive, not curative, services. DIC may occur. Placenta accreta, dysfunctional eggs at night around the perineal area, the first skin reaction caused by an offending allergen.
Rationale: The catchments area in PHN consists labor, and premature rupture of the bowel movement of the day will yield the best The topical allergen that is the most common
of a residential community, many of whom are membranes aren't associated with DIC. results. The specific type of stool specimen causative factor is laundry detergent.
well individuals who have greater need for 27. Answer: (C) 120 to 160 beats/minute used in the diagnosis of pinworms is called the 45. Answer: (A) 6 inches
preventive rather than curative services. Rationale: A rate of 120 to 160 beats/minute in tape test. Rationale: This distance allows for easy flow of
17. Answer: (B) Efficiency the fetal heart appropriate for filling the heart 37. Answer: (A) Irritability and seizures the formula by gravity, but the flow will be slow
Rationale: Efficiency is determining whether the with blood and pumping it out to the system. Rationale: Lead poisoning primarily affects the enough not to overload the stomach too
goals were attained at the least possible cost. 28. Answer: (A) Change the diaper more often. CNS, causing increased intracranial pressure. rapidly.
18. Answer: (D) Rural Health Unit Rationale: Decreasing the amount of time the This condition results in irritability and changes 46. Answer: (A) The older one gets, the more
Rationale: R.A. 7160 devolved basic health skin comes contact with wet soiled diapers will in level of consciousness, as well as seizure susceptible he becomes to the complications of
services to local government units (LGU’s ). The help heal the irritation. disorders, hyperactivity, and learning chicken pox.
public health nurse is an employee of the LGU. 29. Answer: (D) Endocardial cushion defect disabilities. Rationale: Chicken pox is usually more severe in
19. Answer: (A) Mayor Rationale: Endocardial cushion defects are seen 38. Answer: (D) “I really need to use the diaphragm adults than in children. Complications, such as
Rationale: The local executive serves as the most in children with Down syndrome, and jelly most during the middle of my pneumonia, are higher in incidence in adults.
chairman of the Municipal Health Board. asplenia, or polysplenia. menstrual cycle”. 47. Answer: (D) Consult a physician who may give
20. Answer: (A) 1 30. Answer: (B) Decreased urine output Rationale: The woman must understand that, them rubella immunoglobulin.
Rationale: Each rural health midwife is given a Rationale: Decreased urine output may occur in although the “fertile” period is approximately Rationale: Rubella vaccine is made up of
population assignment of about 5,000. clients receiving I.V. magnesium and should be mid-cycle, hormonal variations do occur and attenuated German measles viruses. This is
21. Answer: (B) Health education and community monitored closely to keep urine output at can result in early or late ovulation. To be contraindicated in pregnancy. Immune globulin,
organizing are necessary in providing greater than 30 ml/hour, because magnesium is effective, the diaphragm should be inserted a specific prophylactic against German measles,
community health services. Rationale: The excreted through the kidneys and can easily before every intercourse. may be given to pregnant women.
community health nurse develops the health accumulate to toxic levels. 39. Answer: (C) Restlessness 48. Answer: (A) Contact tracing
capability of people through health education 31. Answer: (A) Menorrhagia Rationale: In a child, restlessness is the earliest Rationale: Contact tracing is the most practical
and community organizing activities. Rationale: Menorrhagia is an excessive sign of hypoxia. Late signs of hypoxia in a child and reliable method of finding possible sources
22. Answer: (B) Measles menstrual period. are associated with a change in color, such as of person-to-person transmitted infections,
Rationale: Presidential Proclamation No. 4 is on 32. Answer: (C) Blood typing pallor or cyanosis. such as sexually transmitted diseases.
the Ligtas Tigdas Program. Rationale: Blood type would be a critical value 40. Answer: (B) Walk one step ahead, with the 49. Answer: (D) Leptospirosis
23. Answer: (D) Core group formation to have because the risk of blood loss is always child’s hand on the nurse’s elbow. Rationale: Leptospirosis is transmitted through
Rationale: In core group formation, the nurse is a potential complication during the labor and Rationale: This procedure is generally contact with the skin or mucous membrane
able to transfer the technology of community delivery process. Approximately 40% of a recommended to follow in guiding a person with water or moist soil contaminated with
organizing to the potential or informal woman’s cardiac output is delivered to the who is blind. urine of infected animals, like rats.
community leaders through a training program. uterus, therefore, blood loss can occur quite 41. Answer: (A) Loud, machinery-like murmur. 50. Answer: (B) Cholera
24. Answer: (D) To maximize the community’s rapidly in the event of uncontrolled bleeding. Rationale: A loud, machinery-like murmur is a Rationale: Passage of profuse watery stools is
resources in dealing with health problems. 33. Answer: (D) Physiologic anemia characteristic finding associated with patent the major symptom of cholera. Both amebic
Rationale: Community organizing is a Rationale: Hemoglobin values and hematocrit ductus arteriosus. and bacillary dysentery are characterized by the
developmental service, with the goal of decrease during pregnancy as the increase in 42. Answer: (C) More oxygen, and the newborn’s presence of blood and/or mucus in the stools.
developing the people’s self-reliance in dealing plasma volume exceeds the increase in red metabolic rate increases. Giardiasis is characterized by fat malabsorption
with community health problems. A, B and C blood cell production. Rationale: When cold, the infant requires more and, therefore, steatorrhea.
are objectives of contributory objectives to this 34. Answer: (D) A 2 year old infant with stridorous oxygen and there is an increase in metabolic 51. Answer: (A) Hemophilus influenzae
goal. breath sounds, sitting up in his mother’s arms rate. Non-shievering thermogenesis is a Rationale: Hemophilus meningitis is unusual
25. Answer: (D) Terminal and drooling. complex process that increases the metabolic over the age of 5 years. In developing countries,
Rationale: Tertiary prevention involves Rationale: The infant with the airway rate and rate of oxygen consumption, the peak incidence is in children less than 6
rehabilitation, prevention of permanent emergency should be treated first, because of therefore, the newborn increase heat months of age. Morbillivirus is the etiology of
disability and disability limitations appropriate the risk of epiglottitis. production. measles. Streptococcus pneumonia and
for convalescents, the disabled, complicated 35. Answer: (A) Placenta previa 43. Answer: (D) Voided Neisseria meningitidis may cause meningitis,
cases and the terminally ill (those in the Rationale: Placenta previa with painless vaginal Rationale: Before administering potassium I.V. but age distribution is not specific in young
terminal stage of a disease). bleeding. to any client, the nurse must first check that the children.
26. Answer: (A) Intrauterine fetal death. 36. Answer: (D) Early in the morning client’s kidneys are functioning and that the 52. Answer: (B) Buccal mucosa
client is voiding. If the client is not voiding, the
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Rationale: Koplik’s spot may be seen on the Rationale: A sick child aged 2 months to 5 years gestation period. Medical care for premature Infants aren’t given tub bath but are sponged
mucosa of the mouth or the throat. must be referred urgently to a hospital if labor begins much earlier (aggressively at 21 off until the cord falls off. Petroleum jelly
53. Answer: (A) 3 seconds he/she has one or more of the following signs: weeks’ gestation) prevents the cord from drying and encourages
Rationale: Adequate blood supply to the area not able to feed or drink, vomits everything, 70. Answer: (B) Sudden infant death syndrome infection. Peroxide could be painful and isn’t
allows the return of the color of the nailbed convulsions, abnormally sleepy or difficult to (SIDS) recommended.
within 3 seconds. awaken. Rationale: Supine positioning is recommended 77. Answer: (B) Conjunctival hemorrhage
54. Answer: (B) Severe dehydration 62. Answer: (A) Refer the child urgently to a to reduce the risk of SIDS in infancy. The risk of Rationale: Conjunctival hemorrhages are
Rationale: The order of priority in the hospital for confinement. aspiration is slightly increased with the supine commonly seen in neonates secondary to the
management of severe dehydration is as Rationale: “Baggy pants” is a sign of severe position. Suffocation would be less likely with cranial pressure applied during the birth
follows: intravenous fluid therapy, referral to a marasmus. The best management is urgent an infant supine than prone and the position process. Bulging fontanelles are a sign of
facility where IV fluids can be initiated within 30 referral to a hospital. for GER requires the head of the bed to be intracranial pressure. Simian creases are
minutes, Oresol or nasogastric tube. When the 63. Answer: (D) Let the child rest for 10 minutes elevated. present in 40% of the neonates with trisomy 21.
foregoing measures are not possible or then continue giving Oresol more slowly. 71. Answer: (C) Decreased temperature Cystic hygroma is a neck mass that can affect
effective, then urgent referral to the hospital is Rationale: If the child vomits persistently, that Rationale: Temperature instability, especially the airway.
done. is, he vomits everything that he takes in, he has when it results in a low temperature in the 78. Answer: (B) To assess for prolapsed cord
55. Answer: (A) 45 infants to be referred urgently to a hospital. Otherwise, neonate, may be a sign of infection. The Rationale: After a client has an amniotomy, the
Rationale: To estimate the number of infants, vomiting is managed by letting the child rest for neonate’s color often changes with an infection nurse should assure that the cord isn't
multiply total population by 3%. 10 minutes and then continuing with Oresol process but generally becomes ashen or prolapsed and that the baby tolerated the
56. Answer: (A) DPT administration. Teach the mother to give Oresol mottled. The neonate with an infection will procedure well. The most effective way to do
Rationale: DPT is sensitive to freezing. The more slowly. usually show a decrease in activity level or this is to check the fetal heart rate. Fetal well-
appropriate storage temperature of DPT is 2 to 64. Answer: (B) Some dehydration lethargy. being is assessed via a nonstress test. Fetal
8° C only. OPV and measles vaccine are highly Rationale: Using the assessment guidelines of 72. Answer: (D) Polycythemia probably due to position is determined by vaginal examination.
sensitive to heat and require freezing. MMR is IMCI, a child (2 months to 5 years old) with chronic fetal hypoxia Artificial rupture of membranes doesn't
not an immunization in the Expanded Program diarrhea is classified as having SOME Rationale: The small-for-gestation neonate is at indicate an imminent delivery.
on Immunization. DEHYDRATION if he shows 2 or more of the risk for developing polycythemia during the 79. Answer: (D) The parents’ interactions with each
57. Answer: (C) Proper use of sanitary toilets following signs: restless or irritable, sunken transitional period in an attempt to decrease other.
Rationale: The ova of the parasite get out of the eyes, the skin goes back slow after a skin pinch. hypoxia. The neonates are also at increased risk Rationale: Parental interaction will provide the
human body together with feces. Cutting the 65. Answer: (C) Normal for developing hypoglycemia and hypothermia nurse with a good assessment of the stability of
cycle at this stage is the most effective way of Rationale: In IMCI, a respiratory rate of due to decreased glycogen stores. the family's home life but it has no indication
preventing the spread of the disease to 50/minute or more is fast breathing for an 73. Answer: (C) Desquamation of the epidermis for parental bonding. Willingness to touch and
susceptible hosts. infant aged 2 to 12 months. Rationale: Postdate fetuses lose the vernix hold the newborn, expressing interest about
58. Answer: (D) 5 skin lesions, positive slit skin 66. Answer: (A) 1 year caseosa, and the epidermis may become the newborn's size, and indicating a desire to
smear Rationale: The baby will have passive natural desquamated. These neonates are usually very see the newborn are behaviors indicating
Rationale: A multibacillary leprosy case is one immunity by placental transfer of antibodies. alert. Lanugo is missing in the postdate parental bonding.
who has a positive slit skin smear and at least 5 The mother will have active artificial immunity neonate. 80. Answer: (B) Instructing the client to use two or
skin lesions. lasting for about 10 years. 5 doses will give the 74. Answer: (C) Respiratory depression more peripads to cushion the area
59. Answer: (C) Thickened painful nerves mother lifetime protection. Rationale: Magnesium sulfate crosses the Rationale: Using two or more peripads would
Rationale: The lesion of leprosy is not macular. 67. Answer: (B) 4 hours placenta and adverse neonatal effects are do little to reduce the pain or promote perineal
It is characterized by a change in skin color Rationale: While the unused portion of other respiratory depression, hypotonia, and healing. Cold applications, sitz baths, and Kegel
(either reddish or whitish) and loss of sensation, biologicals in EPI may be given until the end of bradycardia. The serum blood sugar isn’t exercises are important measures when the
sweating and hair growth over the lesion. the day, only BCG is discarded 4 hours after affected by magnesium sulfate. The neonate client has a fourth-degree laceration.
Inability to close the eyelids (lagophthalmos) reconstitution. This is why BCG immunization is would be floppy, not jittery. 81. Answer: (C) “What is your expected due date?”
and sinking of the nosebridge are late scheduled only in the morning. 75. Answer: (C) Respiratory rate 40 to 60 Rationale: When obtaining the history of a
symptoms. 68. Answer: (B) 6 months breaths/minute client who may be in labor, the nurse's highest
60. Answer: (B) Ask where the family resides. Rationale: After 6 months, the baby’s nutrient Rationale: A respiratory rate 40 to 60 priority is to determine her current status,
Rationale: Because malaria is endemic, the first needs, especially the baby’s iron requirement, breaths/minute is normal for a neonate during particularly her due date, gravidity, and parity.
question to determine malaria risk is where the can no longer be provided by mother’s milk the transitional period. Nasal flaring, Gravidity and parity affect the duration of labor
client’s family resides. If the area of residence is alone. respiratory rate more than 60 breaths/minute, and the potential for labor complications. Later,
not a known endemic area, ask if the child had 69. Answer: (C) 24 weeks and audible grunting are signs of respiratory the nurse should ask about chronic illnesses,
traveled within the past 6 months, where she Rationale: At approximately 23 to 24 weeks’ distress. allergies, and support persons.
was brought and whether she stayed overnight gestation, the lungs are developed enough to 76. Answer: (C) Keep the cord dry and open to air 82. Answer: (D) Aspirate the neonate’s nose and
in that area. sometimes maintain extrauterine life. The lungs Rationale: Keeping the cord dry and open to air mouth with a bulb syringe.
61. Answer: (A) Inability to drink are the most immature system during the helps reduce infection and hastens drying.
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Rationale: The nurse's first action should be to Rationale: The type of placenta that develops in oxygen, and L.V. Fluids. The client usually needs position promotes comfort by taking advantage
clear the neonate's airway with a bulb syringe. monozygotic twins depends on the time at a stronger analgesic than acetaminophen to of gravity. The standing position also takes
After the airway is clear and the neonate's color which cleavage of the ovum occurs. Cleavage in control the pain of a crisis. Antihypertensive advantage of gravity and aligns the fetus with
improves, the nurse should comfort and calm conjoined twins occurs more than 13 days after drugs usually aren’t necessary. Diuretic the pelvic angle.
the neonate. If the problem recurs or the fertilization. Cleavage that occurs less than 3 wouldn’t be used unless fluid overload resulted. 98. Answer: (B) Irritability and poor sucking.
neonate's color doesn't improve readily, the day after fertilization results in diamniotic 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Neonates of heroin-addicted
nurse should notify the physician. dicchorionic twins. Cleavage that occurs Rationale: Calcium gluconate is the antidote for mothers are physically dependent on the drug
Administering oxygen when the airway isn't between days 3 and 8 results in diamniotic magnesium toxicity. Ten milliliters of 10% and experience withdrawal when the drug is no
clear would be ineffective. monochorionic twins. Cleavage that occurs calcium gluconate is given L.V. push over 3 to 5 longer supplied. Signs of heroin withdrawal
83. Answer: (C) Conducting a bedside ultrasound between days 8 to 13 result in monoamniotic minutes. Hydralazine is given for sustained include irritability, poor sucking, and
for an amniotic fluid index. monochorionic twins. elevated blood pressure in preeclamptic clients. restlessness. Lethargy isn't associated with
Rationale: It isn't within a nurse's scope of 88. Answer: (D) Ultrasound Rho (D) immune globulin is given to women neonatal heroin addiction. A flattened nose,
practice to perform and interpret a bedside Rationale: Once the mother and the fetus are with Rh-negative blood to prevent antibody small eyes, and thin lips are seen in infants with
ultrasound under these conditions and without stabilized, ultrasound evaluation of the formation from RH-positive conceptions. fetal alcohol syndrome. Heroin use during
specialized training. Observing for pooling of placenta should be done to determine the Naloxone is used to correct narcotic toxicity. pregnancy hasn't been linked to specific
straw-colored fluid, checking vaginal discharge cause of the bleeding. Amniocentesis is 94. Answer: (B) An indurated wheal over 10 mm in congenital anomalies.
with nitrazine paper, and observing for flakes of contraindicated in placenta previa. A digital or diameter appears in 48 to 72 hours. 99. Answer: (A) 7th to 9th day postpartum
vernix are appropriate assessments for speculum examination shouldn’t be done as Rationale: A positive PPD result would be an Rationale: The normal involutional process
determining whether a client has ruptured this may lead to severe bleeding or indurated wheal over 10 mm in diameter that returns the uterus to the pelvic cavity in 7 to 9
membranes. hemorrhage. External fetal monitoring won’t appears in 48 to 72 hours. The area must be a days. A significant involutional complication is
84. Answer: (C) Monitor partial pressure of oxygen detect a placenta previa, although it will detect raised wheal, not a flat circumcised area to be the failure of the uterus to return to the pelvic
(Pao2) levels. fetal distress, which may result from blood loss considered positive. cavity within the prescribed time period. This is
Rationale: Monitoring PaO2 levels and reducing or placenta separation. 95. Answer: (C) Pyelonephritis known as subinvolution.
the oxygen concentration to keep PaO2 within 89. Answer: (A) Increased tidal volume Rationale The symptoms indicate acute 100. Answer: (B) Uterine atony
normal limits reduces the risk of retinopathy of Rationale: A pregnant client breathes deeper, pyelonephritis, a serious condition in a Rationale: Multiple fetuses, extended labor
prematurity in a premature infant receiving which increases the tidal volume of gas moved pregnant client. UTI symptoms include dysuria, stimulation with oxytocin, and traumatic
oxygen. Covering the infant's eyes and in and out of the respiratory tract with each urgency, frequency, and suprapubic delivery commonly are associated with uterine
humidifying the oxygen don't reduce the risk of breath. The expiratory volume and residual tenderness. Asymptomatic bacteriuria doesn’t atony, which may lead to postpartum
retinopathy of prematurity. Because cooling volume decrease as the pregnancy progresses. cause symptoms. Bacterial vaginosis causes hemorrhage. Uterine inversion may precede or
increases the risk of acidosis, the infant should The inspiratory capacity increases during milky white vaginal discharge but no systemic follow delivery and commonly results from
be kept warm so that his respiratory distress pregnancy. The increased oxygen consumption symptoms. apparent excessive traction on the umbilical
isn't aggravated. in the pregnant client is 15% to 20% greater 96. Answer: (B) Rh-positive fetal blood crosses into cord and attempts to deliver the placenta
85. Answer: (A) 110 to 130 calories per kg. than in the nonpregnant state. maternal blood, stimulating maternal manually. Uterine involution and some uterine
Rationale: Calories per kg is the accepted way 90. Answer: (A) Diet antibodies. discomfort are normal after delivery.
of determined appropriate nutritional intake Rationale: Clients with gestational diabetes are Rationale: Rh isoimmunization occurs when Rh-
for a newborn. The recommended calorie usually managed by diet alone to control their positive fetal blood cells cross into the maternal
requirement is 110 to 130 calories per kg of glucose intolerance. Oral hypoglycemic drugs circulation and stimulate maternal antibody
newborn body weight. This level will maintain a are contraindicated in pregnancy. Long-acting production. In subsequent pregnancies with Rh-
consistent blood glucose level and provide insulin usually isn’t needed for blood glucose positive fetuses, maternal antibodies may cross
enough calories for continued growth and control in the client with gestational diabetes. back into the fetal circulation and destroy the
development. 91. Answer: (D) Seizure fetal blood cells.
86. Answer: (C) 30 to 32 weeks Rationale: The anticonvulsant mechanism of 97. Answer: (C) Supine position
Rationale: Individual twins usually grow at the magnesium is believes to depress seizure foci in Rationale: The supine position causes
same rate as singletons until 30 to 32 weeks’ the brain and peripheral neuromuscular compression of the client's aorta and inferior
gestation, then twins don’t’ gain weight as blockade. Hypomagnesemia isn’t a vena cava by the fetus. This, in turn, inhibits
rapidly as singletons of the same gestational complication of preeclampsia. Antihypertensive maternal circulation, leading to maternal
age. The placenta can no longer keep pace with drug other than magnesium are preferred for hypotension and, ultimately, fetal hypoxia. The
the nutritional requirements of both fetuses sustained hypertension. Magnesium doesn’t other positions promote comfort and aid labor
after 32 weeks, so there’s some growth help prevent hemorrhage in preeclamptic progress. For instance, the lateral, or side-lying,
retardation in twins if they remain in utero at clients. position improves maternal and fetal
38 to 40 weeks. 92. Answer: (C) I.V. fluids circulation, enhances comfort, increases
87. Answer: (A) conjoined twins Rationale: A sickle cell crisis during pregnancy is maternal relaxation, reduces muscle tension,
usually managed by exchange transfusion and eliminates pressure points. The squatting
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TEST III - Care of Clients with Physiologic and 6. Nurse Monett is caring for a client recovering d. The client refuses dinner because of 16. Nurse John is caring for a male client receiving
Psychosocial Alterations from gastro-intestinal bleeding. The nurse anorexia. lidocaine I.V. Which factor is the most relevant
should: to administration of this medication?
1. Nurse Michelle should know that the drainage is a. Plan care so the client can receive 8 11. Mrs. Cruz, 80 years old is diagnosed with a. Decrease in arterial oxygen saturation
normal 4 days after a sigmoid colostomy when hours of uninterrupted sleep each night. pneumonia. Which of the following symptoms (SaO2) when measured with a pulse
the stool is: b. Monitor vital signs every 2 hours. may appear first? oximeter.
a. Green liquid c. Make sure that the client takes food and a. Altered mental status and dehydration b. Increase in systemic blood pressure.
b. Solid formed medications at prescribed intervals. b. Fever and chills c. Presence of premature ventricular
c. Loose, bloody d. Provide milk every 2 to 3 hours. c. Hemoptysis and Dyspnea contractions (PVCs) on a cardiac
d. Semiformed d. Pleuritic chest pain and cough monitor.
7. A male client was on warfarin (Coumadin) before d. Increase in intracranial pressure (ICP).
2. Where would nurse Kristine place the call light admission, and has been receiving heparin I.V. 12. A male client has active tuberculosis (TB). Which
for a male client with a right-sided brain attack for 2 days. The partial thromboplastin time (PTT) of the following symptoms will be exhibit? 17. Nurse Ron is caring for a male client taking an
and left homonymous hemianopsia? is 68 seconds. What should Nurse Carla do? a. Chest and lower back pain anticoagulant. The nurse should teach the client
a. On the client’s right side a. Stop the I.V. infusion of heparin and b. Chills, fever, night sweats, and to:
b. On the client’s left side notify the physician. hemoptysis a. Report incidents of diarrhea.
c. Directly in front of the client b. Continue treatment as ordered. c. Fever of more than 104°F (40°C) and b. Avoid foods high in vitamin K
d. Where the client like c. Expect the warfarin to increase the PTT. nausea c. Use a straight razor when shaving.
d. Increase the dosage, because the level is d. Headache and photophobia d. Take aspirin to pain relief.
3. A male client is admitted to the emergency lower than normal.
department following an accident. What are the 13. Mark, a 7-year-old client is brought to the 18. Nurse Lhynnette is preparing a site for the
first nursing actions of the nurse? 8. A client undergone ileostomy, when should the emergency department. He’s tachypneic and insertion of an I.V. catheter. The nurse should
a. Check respiration, circulation, drainage appliance be applied to the stoma? afebrile and has a respiratory rate of 36 treat excess hair at the site by:
neurological response. a. 24 hours later, when edema has breaths/minute and has a nonproductive cough. a. Leaving the hair intact
b. Align the spine, check pupils, and check subsided. He recently had a cold. Form this history; the b. Shaving the area
for hemorrhage. b. In the operating room. client may have which of the following c. Clipping the hair in the area
c. Check respirations, stabilize spine, and c. After the ileostomy begin to function. conditions? d. Removing the hair with a depilatory.
check circulation. d. When the client is able to begin self-care a. Acute asthma
d. Assess level of consciousness and procedures. b. Bronchial pneumonia 19. Nurse Michelle is caring for an elderly female
circulation. c. Chronic obstructive pulmonary disease with osteoporosis. When teaching the client, the
9. A client undergone spinal anesthetic, it will be (COPD) nurse should include information about which
4. In evaluating the effect of nitroglycerin, Nurse important that the nurse immediately position d. Emphysema major complication:
Arthur should know that it reduces preload and the client in: a. Bone fracture
relieves angina by: a. On the side, to prevent obstruction of 14. Marichu was given morphine sulfate for pain. b. Loss of estrogen
a. Increasing contractility and slowing airway by tongue. She is sleeping and her respiratory rate is 4 c. Negative calcium balance
heart rate. b. Flat on back. breaths/minute. If action isn’t taken quickly, she d. Dowager’s hump
b. Increasing AV conduction and heart rate. c. On the back, with knees flexed 15 might have which of the following reactions?
c. Decreasing contractility and oxygen degrees. a. Asthma attack 20. Nurse Len is teaching a group of women to
consumption. d. Flat on the stomach, with the head b. Respiratory arrest perform BSE. The nurse should explain that the
d. Decreasing venous return through turned to the side. c. Seizure purpose of performing the examination is to
vasodilation. d. Wake up on his own discover:
10. While monitoring a male client several hours a. Cancerous lumps
5. Nurse Patricia finds a female client who is post- after a motor vehicle accident, which 15. A 77-year-old male client is admitted for elective b. Areas of thickness or fullness
myocardial infarction (MI) slumped on the side assessment data suggest increasing intracranial knee surgery. Physical examination reveals c. Changes from previous examinations.
rails of the bed and unresponsive to shaking or pressure? shallow respirations but no sign of respiratory d. Fibrocystic masses
shouting. Which is the nurse next action? a. Blood pressure is decreased from distress. Which of the following is a normal
a. Call for help and note the time. 160/90 to 110/70. physiologic change related to aging? 21. When caring for a female client who is being
b. Clear the airway b. Pulse is increased from 87 to 95, with an a. Increased elastic recoil of the lungs treated for hyperthyroidism, it is important to:
c. Give two sharp thumps to the occasional skipped beat. b. Increased number of functional a. Provide extra blankets and clothing to
precordium, and check the pulse. c. The client is oriented when aroused capillaries in the alveoli keep the client warm.
d. Administer two quick blows. from sleep, and goes back to sleep c. Decreased residual volume b. Monitor the client for signs of
immediately. d. Decreased vital capacity restlessness, sweating, and excessive
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weight loss during thyroid replacement During routine assessment, the nurse notices b. Kinked or obstructed chest tube tuberculosis (TB). Which of the following clients
therapy. Cheyne- Strokes respirations. Cheyne-strokes c. Excessive water in the water-seal entering the clinic today most likely to have TB?
c. Balance the client’s periods of activity respirations are: chamber a. A 16-year-old female high school
and rest. a. A progressively deeper breaths followed d. Excessive chest tube drainage student
d. Encourage the client to be active to by shallower breaths with apneic b. A 33-year-old day-care worker
prevent constipation. periods. 32. Nurse Maureen is talking to a male client; the c. A 43-yesr-old homeless man with a
b. Rapid, deep breathing with abrupt client begins choking on his lunch. He’s coughing history of alcoholism
22. Nurse Kris is teaching a client with history of pauses between each breath. forcefully. The nurse should: d. A 54-year-old businessman
atherosclerosis. To decrease the risk of c. Rapid, deep breathing and irregular a. Stand him up and perform the
atherosclerosis, the nurse should encourage the breathing without pauses. abdominal thrust maneuver from 37. Virgie with a positive Mantoux test result will be
client to: d. Shallow breathing with an increased behind. sent for a chest X-ray. The nurse is aware that
a. Avoid focusing on his weight. respiratory rate. b. Lay him down, straddle him, and which of the following reasons this is done?
b. Increase his activity level. perform the abdominal thrust a. To confirm the diagnosis
c. Follow a regular diet. 28. Nurse Bea is assessing a male client with heart maneuver. b. To determine if a repeat skin test is
d. Continue leading a high-stress lifestyle. failure. The breath sounds commonly c. Leave him to get assistance needed
auscultated in clients with heart failure are: d. Stay with him but not intervene at this c. To determine the extent of lesions
23. Nurse Greta is working on a surgical floor. Nurse a. Tracheal time. d. To determine if this is a primary or
Greta must logroll a client following a: b. Fine crackles secondary infection
a. Laminectomy c. Coarse crackles 33. Nurse Ron is taking a health history of an 84 year
b. Thoracotomy d. Friction rubs old client. Which information will be most useful 38. Kennedy with acute asthma showing inspiratory
c. Hemorrhoidectomy to the nurse for planning care? and expiratory wheezes and a decreased forced
d. Cystectomy. 29. The nurse is caring for Kenneth experiencing an a. General health for the last 10 years. expiratory volume should be treated with which
acute asthma attack. The client stops wheezing b. Current health promotion activities. of the following classes of medication right
24. A 55-year old client underwent cataract removal and breath sounds aren’t audible. The reason for c. Family history of diseases. away?
with intraocular lens implant. Nurse Oliver is this change is that: d. Marital status. a. Beta-adrenergic blockers
giving the client discharge instructions. These a. The attack is over. b. Bronchodilators
instructions should include which of the b. The airways are so swollen that no air 34. When performing oral care on a comatose client, c. Inhaled steroids
following? cannot get through. Nurse Krina should: d. Oral steroids
a. Avoid lifting objects weighing more than c. The swelling has decreased. a. Apply lemon glycerin to the client’s lips
5 lb (2.25 kg). d. Crackles have replaced wheezes. at least every 2 hours. 39. Mr. Vasquez 56-year-old client with a 40-year
b. Lie on your abdomen when in bed b. Brush the teeth with client lying supine. history of smoking one to two packs of cigarettes
c. Keep rooms brightly lit. 30. Mike with epilepsy is having a seizure. During c. Place the client in a side lying position, per day has a chronic cough producing thick
d. Avoiding straining during bowel the active seizure phase, the nurse should: with the head of the bed lowered. sputum, peripheral edema and cyanotic nail
movement or bending at the waist. a. Place the client on his back remove d. Clean the client’s mouth with hydrogen beds. Based on this information, he most likely
dangerous objects, and insert a bite peroxide. has which of the following conditions?
25. George should be taught about testicular block. a. Adult respiratory distress syndrome
examinations during: b. Place the client on his side, remove 35. A 77-year-old male client is admitted with a (ARDS)
a. when sexual activity starts dangerous objects, and insert a bite diagnosis of dehydration and change in mental b. Asthma
b. After age 69 block. status. He’s being hydrated with L.V. fluids. c. Chronic obstructive bronchitis
c. After age 40 c. Place the client o his back, remove When the nurse takes his vital signs, she notes d. Emphysema
d. Before age 20. dangerous objects, and hold down his he has a fever of 103°F (39.4°C) a cough
26. A male client undergone a colon resection. While arms. producing yellow sputum and pleuritic chest Situation: Francis, age 46 is admitted to the hospital with
turning him, wound dehiscence with d. Place the client on his side, remove pain. The nurse suspects this client may have diagnosis of Chronic Lymphocytic Leukemia.
evisceration occurs. Nurse Trish first response is dangerous objects, and protect his head. which of the following conditions?
to: a. Adult respiratory distress syndrome 40. The treatment for patients with leukemia is bone
a. Call the physician 31. After insertion of a cheat tube for a (ARDS) marrow transplantation. Which statement about
b. Place a saline-soaked sterile dressing on pneumothorax, a client becomes hypotensive b. Myocardial infarction (MI) bone marrow transplantation is not correct?
the wound. with neck vein distention, tracheal shift, absent c. Pneumonia a. The patient is under local anesthesia
c. Take a blood pressure and pulse. breath sounds, and diaphoresis. Nurse Amanda d. Tuberculosis during the procedure
d. Pull the dehiscence closed. suspects a tension pneumothorax has occurred. b. The aspirated bone marrow is mixed
What cause of tension pneumothorax should the 36. Nurse Oliver is working in an outpatient clinic. with heparin.
27. Nurse Audrey is caring for a client who has nurse check for? He has been alerted that there is an outbreak of c. The aspiration site is the posterior or
suffered a severe cerebrovascular accident. a. Infection of the lung. anterior iliac crest.
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d. The recipient receives pressure of 126/76 mm Hg, and a according to the TNM staging system as follows: a. prostate-specific antigen, which is used
cyclophosphamide (Cytoxan) for 4 respiratory rate of 22 breaths/ minute. TIS, N0, M0. What does this classification mean? to screen for prostate cancer.
consecutive days before the procedure. b. The 89-year-old client with end-stage a. No evidence of primary tumor, no b. protein serum antigen, which is used to
41. After several days of admission, Francis becomes right-sided heart failure, blood pressure abnormal regional lymph nodes, and no determine protein levels.
disoriented and complains of frequent of 78/50 mm Hg, and a “do not evidence of distant metastasis c. pneumococcal strep antigen, which is a
headaches. The nurse in-charge first action resuscitate” order b. Carcinoma in situ, no abnormal regional bacteria that causes pneumonia.
would be: c. The 62-year-old client who was admitted lymph nodes, and no evidence of distant d. Papanicolaou-specific antigen, which is
a. Call the physician 1 day ago with thrombophlebitis and is metastasis used to screen for cervical cancer.
b. Document the patient’s status in his receiving L.V. heparin c. Can't assess tumor or regional lymph
charts. d. The 75-year-old client who was admitted nodes and no evidence of metastasis 54. What is the most important postoperative
c. Prepare oxygen treatment 1 hour ago with new-onset atrial d. Carcinoma in situ, no demonstrable instruction that nurse Kate must give a client
d. Raise the side rails fibrillation and is receiving L.V. dilitiazem metastasis of the regional lymph nodes, who has just returned from the operating room
(Cardizem) and ascending degrees of distant after receiving a subarachnoid block?
42. During routine care, Francis asks the nurse, metastasis a. "Avoid drinking liquids until the gag
“How can I be anemic if this disease causes 46. Honey, a 23-year old client complains of reflex returns."
increased my white blood cell production?” The substernal chest pain and states that her heart 50. Lydia undergoes a laryngectomy to treat b. "Avoid eating milk products for 24
nurse in-charge best response would be that the feels like “it’s racing out of the chest”. She laryngeal cancer. When teaching the client how hours."
increased number of white blood cells (WBC) is: reports no history of cardiac disorders. The to care for the neck stoma, the nurse should c. "Notify a nurse if you experience blood
a. Crowd red blood cells nurse attaches her to a cardiac monitor and include which instruction? in your urine."
b. Are not responsible for the anemia. notes sinus tachycardia with a rate of a. "Keep the stoma uncovered." d. "Remain supine for the time specified by
c. Uses nutrients from other cells 136beats/minutes. Breath sounds are clear and b. "Keep the stoma dry." the physician."
d. Have an abnormally short life span of the respiratory rate is 26 breaths/minutes. c. "Have a family member perform stoma
cells. Which of the following drugs should the nurse care initially until you get used to the 55. A male client suspected of having colorectal
question the client about using? procedure." cancer will require which diagnostic study to
43. Diagnostic assessment of Francis would probably a. Barbiturates d. "Keep the stoma moist." confirm the diagnosis?
not reveal: b. Opioids a. Stool Hematest
a. Predominance of lymhoblasts c. Cocaine 51. A 37-year-old client with uterine cancer asks the b. Carcinoembryonic antigen (CEA)
b. Leukocytosis d. Benzodiazepines nurse, "Which is the most common type of c. Sigmoidoscopy
c. Abnormal blast cells in the bone marrow cancer in women?" The nurse replies that it's d. Abdominal computed tomography (CT)
d. Elevated thrombocyte counts 47. A 51-year-old female client tells the nurse in- breast cancer. Which type of cancer causes the scan
charge that she has found a painless lump in her most deaths in women?
44. Robert, a 57-year-old client with acute arterial right breast during her monthly self- a. Breast cancer 56. During a breast examination, which finding most
occlusion of the left leg undergoes an examination. Which assessment finding would b. Lung cancer strongly suggests that the Luz has breast cancer?
emergency embolectomy. Six hours later, the strongly suggest that this client's lump is c. Brain cancer a. Slight asymmetry of the breasts.
nurse isn’t able to obtain pulses in his left foot cancerous? d. Colon and rectal cancer b. A fixed nodular mass with dimpling of
using Doppler ultrasound. The nurse a. Eversion of the right nipple and mobile the overlying skin
immediately notifies the physician, and asks her mass 52. Antonio with lung cancer develops Horner's c. Bloody discharge from the nipple
to prepare the client for surgery. As the nurse b. Nonmobile mass with irregular edges syndrome when the tumor invades the ribs and d. Multiple firm, round, freely movable
enters the client’s room to prepare him, he c. Mobile mass that is soft and easily affects the sympathetic nerve ganglia. When masses that change with the menstrual
states that he won’t have any more surgery. delineated assessing for signs and symptoms of this cycle
Which of the following is the best initial d. Nonpalpable right axillary lymph nodes syndrome, the nurse should note:
response by the nurse? a. miosis, partial eyelid ptosis, and 57. A female client with cancer is being evaluated
a. Explain the risks of not having the 48. A 35-year-old client with vaginal cancer asks the anhidrosis on the affected side of the for possible metastasis. Which of the following is
surgery nurse, "What is the usual treatment for this type face. one of the most common metastasis sites for
b. Notifying the physician immediately of cancer?" Which treatment should the nurse b. chest pain, dyspnea, cough, weight loss, cancer cells?
c. Notifying the nursing supervisor name? and fever. a. Liver
d. Recording the client’s refusal in the a. Surgery c. arm and shoulder pain and atrophy of b. Colon
nurses’ notes b. Chemotherapy arm and hand muscles, both on the c. Reproductive tract
c. Radiation affected side. d. White blood cells (WBCs)
45. During the endorsement, which of the following d. Immunotherapy d. hoarseness and dysphagia.
clients should the on-duty nurse assess first? 58. Nurse Mandy is preparing a client for magnetic
a. The 58-year-old client who was admitted 49. Cristina undergoes a biopsy of a suspicious 53. Vic asks the nurse what PSA is. The nurse should resonance imaging (MRI) to confirm or rule out a
2 days ago with heart failure, blood lesion. The biopsy report classifies the lesion reply that it stands for:
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spinal cord lesion. During the MRI scan, which of 63. A 76-year-old male client had a thromboembolic a. 9 U regular insulin and 21 U neutral c. Restricting fluids
the following would pose a threat to the client? right stroke; his left arm is swollen. Which of the protamine Hagedorn (NPH). d. Administering glucose-containing I.V.
a. The client lies still. following conditions may cause swelling after a b. 21 U regular insulin and 9 U NPH. fluids as ordered
b. The client asks questions. stroke? c. 10 U regular insulin and 20 U NPH.
c. The client hears thumping sounds. a. Elbow contracture secondary to d. 20 U regular insulin and 10 U NPH. 73. A female client tells nurse Nikki that she has
d. The client wears a watch and wedding spasticity been working hard for the last 3 months to
band. b. Loss of muscle contraction decreasing 68. Nurse Len should expect to administer which control her type 2 diabetes mellitus with diet
venous return medication to a client with gout? and exercise. To determine the effectiveness of
59. Nurse Cecile is teaching a female client about c. Deep vein thrombosis (DVT) due to a. aspirin the client's efforts, the nurse should check:
preventing osteoporosis. Which of the following immobility of the ipsilateral side b. furosemide (Lasix) a. urine glucose level.
teaching points is correct? d. Hypoalbuminemia due to protein c. colchicines b. fasting blood glucose level.
a. Obtaining an X-ray of the bones every 3 escaping from an inflamed glomerulus d. calcium gluconate (Kalcinate) c. serum fructosamine level.
years is recommended to detect bone d. glycosylated hemoglobin level.
loss. 64. Heberden’s nodes are a common sign of 69. Mr. Domingo with a history of hypertension is
b. To avoid fractures, the client should osteoarthritis. Which of the following statement diagnosed with primary hyperaldosteronism. 74. Nurse Trinity administered neutral protamine
avoid strenuous exercise. is correct about this deformity? This diagnosis indicates that the client's Hagedorn (NPH) insulin to a diabetic client at 7
c. The recommended daily allowance of a. It appears only in men hypertension is caused by excessive hormone a.m. At what time would the nurse expect the
calcium may be found in a wide variety b. It appears on the distal interphalangeal secretion from which of the following glands? client to be most at risk for a hypoglycemic
of foods. joint a. Adrenal cortex reaction?
d. Obtaining the recommended daily c. It appears on the proximal b. Pancreas a. 10:00 am
allowance of calcium requires taking a interphalangeal joint c. Adrenal medulla b. Noon
calcium supplement. d. It appears on the dorsolateral aspect of d. Parathyroid c. 4:00 pm
the interphalangeal joint. d. 10:00 pm
60. Before Jacob undergoes arthroscopy, the nurse 70. For a diabetic male client with a foot ulcer, the
reviews the assessment findings for 65. Which of the following statements explains the doctor orders bed rest, a wet-to-dry dressing 75. The adrenal cortex is responsible for producing
contraindications for this procedure. Which main difference between rheumatoid arthritis change every shift, and blood glucose which substances?
finding is a contraindication? and osteoarthritis? monitoring before meals and bedtime. Why are a. Glucocorticoids and androgens
a. Joint pain a. Osteoarthritis is gender-specific, wet-to-dry dressings used for this client? b. Catecholamines and epinephrine
b. Joint deformity rheumatoid arthritis isn’t a. They contain exudate and provide a c. Mineralocorticoids and catecholamines
c. Joint flexion of less than 50% b. Osteoarthritis is a localized disease moist wound environment. d. Norepinephrine and epinephrine
d. Joint stiffness rheumatoid arthritis is systemic b. They protect the wound from
c. Osteoarthritis is a systemic disease, mechanical trauma and promote 76. On the third day after a partial thyroidectomy,
61. Mr. Rodriguez is admitted with severe pain in rheumatoid arthritis is localized healing. Proserfina exhibits muscle twitching and
the knees. Which form of arthritis is d. Osteoarthritis has dislocations and c. They debride the wound and promote hyperirritability of the nervous system. When
characterized by urate deposits and joint pain, subluxations, rheumatoid arthritis healing by secondary intention. questioned, the client reports numbness and
usually in the feet and legs, and occurs primarily doesn’t d. They prevent the entrance of tingling of the mouth and fingertips. Suspecting
in men over age 30? microorganisms and minimize wound a life-threatening electrolyte disturbance, the
a. Septic arthritis 66. Mrs. Cruz uses a cane for assistance in walking. discomfort. nurse notifies the surgeon immediately. Which
b. Traumatic arthritis Which of the following statements is true about electrolyte disturbance most commonly follows
c. Intermittent arthritis a cane or other assistive devices? 71. Nurse Zeny is caring for a client in acute thyroid surgery?
d. Gouty arthritis a. A walker is a better choice than a cane. addisonian crisis. Which laboratory data would a. Hypocalcemia
b. The cane should be used on the affected the nurse expect to find? b. Hyponatremia
62. A heparin infusion at 1,500 unit/hour is ordered side a. Hyperkalemia c. Hyperkalemia
for a 64-year-old client with stroke in evolution. c. The cane should be used on the b. Reduced blood urea nitrogen (BUN) d. Hypermagnesemia
The infusion contains 25,000 units of heparin in unaffected side c. Hypernatremia
500 ml of saline solution. How many milliliters d. A client with osteoarthritis should be d. Hyperglycemia 77. Which laboratory test value is elevated in clients
per hour should be given? encouraged to ambulate without the who smoke and can't be used as a general
a. 15 ml/hour cane 72. A client is admitted for treatment of the indicator of cancer?
b. 30 ml/hour syndrome of inappropriate antidiuretic hormone a. Acid phosphatase level
c. 45 ml/hour 67. A male client with type 1 diabetes is scheduled (SIADH). Which nursing intervention is b. Serum calcitonin level
d. 50 ml/hour to receive 30 U of 70/30 insulin. There is no appropriate? c. Alkaline phosphatase level
70/30 insulin available. As a substitution, the a. Infusing I.V. fluids rapidly as ordered d. Carcinoembryonic antigen level
nurse may give the client: b. Encouraging increased oral intake
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78. Francis with anemia has been admitted to the c. Administer the antidote for penicillin, as a. E-rosette immunofluorescence. d. A client with rheumatoid arthritis who
medical-surgical unit. Which assessment findings prescribed, and continue to monitor the b. quantification of T-lymphocytes. states, “I am having trouble sleeping.”
are characteristic of iron-deficiency anemia? client's vital signs. c. enzyme-linked immunosorbent assay
a. Nights sweats, weight loss, and diarrhea d. Insert an indwelling urinary catheter and (ELISA). 92. Nurse Sarah is caring for clients on the surgical
b. Dyspnea, tachycardia, and pallor begin to infuse I.V. fluids as ordered. d. Western blot test with ELISA. floor and has just received report from the
c. Nausea, vomiting, and anorexia previous shift. Which of the following clients
d. Itching, rash, and jaundice 83. Mr. Marquez with rheumatoid arthritis is about 88. A complete blood count is commonly performed should the nurse see first?
to begin aspirin therapy to reduce inflammation. before a Joe goes into surgery. What does this a. A 35-year-old admitted three hours ago
79. In teaching a female client who is HIV-positive When teaching the client about aspirin, the test seek to identify? with a gunshot wound; 1.5 cm area of
about pregnancy, the nurse would know more nurse discusses adverse reactions to prolonged a. Potential hepatic dysfunction indicated dark drainage noted on the dressing.
teaching is necessary when the client says: aspirin therapy. These include: by decreased blood urea nitrogen (BUN) b. A 43-year-old who had a mastectomy
a. The baby can get the virus from my a. weight gain. and creatinine levels two days ago; 23 ml of serosanguinous
placenta." b. fine motor tremors. b. Low levels of urine constituents normally fluid noted in the Jackson-Pratt drain.
b. "I'm planning on starting on birth control c. respiratory acidosis. excreted in the urine c. A 59-year-old with a collapsed lung due
pills." d. bilateral hearing loss. c. Abnormally low hematocrit (HCT) and to an accident; no drainage noted in the
c. "Not everyone who has the virus gives hemoglobin (Hb) levels previous eight hours.
birth to a baby who has the virus." 84. A 23-year-old client is diagnosed with human d. Electrolyte imbalance that could affect d. A 62-year-old who had an abdominal-
d. "I'll need to have a C-section if I become immunodeficiency virus (HIV). After recovering the blood's ability to coagulate properly perineal resection three days ago; client
pregnant and have a baby." from the initial shock of the diagnosis, the client complaints of chills.
expresses a desire to learn as much as possible 89. While monitoring a client for the development
80. When preparing Judy with acquired about HIV and acquired immunodeficiency of disseminated intravascular coagulation (DIC), 93. Nurse Eve is caring for a client who had a
immunodeficiency syndrome (AIDS) for syndrome (AIDS). When teaching the client the nurse should take note of what assessment thyroidectomy 12 hours ago for treatment of
discharge to the home, the nurse should be sure about the immune system, the nurse states that parameters? Grave’s disease. The nurse would be most
to include which instruction? adaptive immunity is provided by which type of a. Platelet count, prothrombin time, and concerned if which of the following was
a. "Put on disposable gloves before white blood cell? partial thromboplastin time observed?
bathing." a. Neutrophil b. Platelet count, blood glucose levels, and a. Blood pressure 138/82, respirations 16,
b. "Sterilize all plates and utensils in boiling b. Basophil white blood cell (WBC) count oral temperature 99 degrees Fahrenheit.
water." c. Monocyte c. Thrombin time, calcium levels, and b. The client supports his head and neck
c. "Avoid sharing such articles as d. Lymphocyte potassium levels when turning his head to the right.
toothbrushes and razors." d. Fibrinogen level, WBC, and platelet c. The client spontaneously flexes his wrist
d. "Avoid eating foods from serving dishes 85. In an individual with Sjögren's syndrome, nursing count when the blood pressure is obtained.
shared by other family members." care should focus on: d. The client is drowsy and complains of
a. moisture replacement. 90. When taking a dietary history from a newly sore throat.
81. Nurse Marie is caring for a 32-year-old client b. electrolyte balance. admitted female client, Nurse Len should
admitted with pernicious anemia. Which set of c. nutritional supplementation. remember that which of the following foods is a 94. Julius is admitted with complaints of severe pain
findings should the nurse expect when assessing d. arrhythmia management. common allergen? in the lower right quadrant of the abdomen. To
the client? a. Bread assist with pain relief, the nurse should take
a. Pallor, bradycardia, and reduced pulse 86. During chemotherapy for lymphocytic leukemia, b. Carrots which of the following actions?
pressure Mathew develops abdominal pain, fever, and c. Orange a. Encourage the client to change positions
b. Pallor, tachycardia, and a sore tongue "horse barn" smelling diarrhea. It would be most d. Strawberries frequently in bed.
c. Sore tongue, dyspnea, and weight gain important for the nurse to advise the physician b. Administer Demerol 50 mg IM q 4 hours
d. Angina, double vision, and anorexia to order: 91. Nurse John is caring for clients in the outpatient and PRN.
a. enzyme-linked immunosuppressant clinic. Which of the following phone calls should c. Apply warmth to the abdomen with a
82. After receiving a dose of penicillin, a client assay (ELISA) test. the nurse return first? heating pad.
develops dyspnea and hypotension. Nurse b. electrolyte panel and hemogram. a. A client with hepatitis A who states, “My d. Use comfort measures and pillows to
Celestina suspects the client is experiencing c. stool for Clostridium difficile test. arms and legs are itching.” position the client.
anaphylactic shock. What should the nurse do d. flat plate X-ray of the abdomen. b. A client with cast on the right leg who
first? states, “I have a funny feeling in my right 95. Nurse Tina prepares a client for peritoneal
a. Page an anesthesiologist immediately 87. A male client seeks medical evaluation for leg.” dialysis. Which of the following actions should
and prepare to intubate the client. fatigue, night sweats, and a 20-lb weight loss in 6 c. A client with osteomyelitis of the spine the nurse take first?
b. Administer epinephrine, as prescribed, weeks. To confirm that the client has been who states, “I am so nauseous that I a. Assess for a bruit and a thrill.
and prepare to intubate the client if infected with the human immunodeficiency virus can’t eat.” b. Warm the dialysate solution.
necessary. (HIV), the nurse expects the physician to order: c. Position the client on the left side.
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d. Insert a Foley catheter takes small steps while balancing on the digestive enzymes and highly irritating to the
walker. skin. Protection of the skin from the effects of
96. Nurse Jannah teaches an elderly client with d. The client slides the walker 18 inches Answers and Rationale – Care of Clients with these enzymes is begun at once. Skin exposed
right-sided weakness how to use cane. Which of forward, then takes small steps while Physiologic and Psychosocial Alterations to these enzymes even for a short time
the following behaviors, if demonstrated by the holding onto the walker for balance. becomes reddened, painful, and excoriated.
client to the nurse, indicates that the teaching 1. Answer: (C) Loose, bloody 9. Answer: (B) Flat on back.
was effective? 99. Nurse Deric is supervising a group of elderly Rationale: Normal bowel function and soft- Rationale: To avoid the complication of a
a. The client holds the cane with his right clients in a residential home setting. The nurse formed stool usually do not occur until around painful spinal headache that can last for
hand, moves the can forward followed knows that the elderly are at greater risk of the seventh day following surgery. The stool several days, the client is kept in flat in a
by the right leg, and then moves the left developing sensory deprivation for what reason? consistency is related to how much water is supine position for approximately 4 to 12
leg. a. Increased sensitivity to the side effects being absorbed. hours postoperatively. Headaches are
b. The client holds the cane with his right of medications. 2. Answer: (A) On the client’s right side believed to be causes by the seepage of
hand, moves the cane forward followed b. Decreased visual, auditory, and Rationale: The client has left visual field cerebral spinal fluid from the puncture site. By
by his left leg, and then moves the right gustatory abilities. blindness. The client will see only from the keeping the client flat, cerebral spinal fluid
leg. c. Isolation from their families and familiar right side. pressures are equalized, which avoids trauma
c. The client holds the cane with his left surroundings. 3. Answer: (C) Check respirations, stabilize spine, to the neurons.
hand, moves the cane forward followed d. Decrease musculoskeletal function and and check circulation 10. Answer: (C) The client is oriented when
by the right leg, and then moves the left mobility. Rationale: Checking the airway would be aroused from sleep, and goes back to sleep
leg. priority, and a neck injury should be immediately.
d. The client holds the cane with his left 100. A male client with emphysema becomes suspected. Rationale: This finding suggest that the level
hand, moves the cane forward followed restless and confused. What step should 4. Answer: (D) Decreasing venous return through of consciousness is decreasing.
by his left leg, and then moves the right nurse Jasmine take next? vasodilation. 11. Answer: (A) Altered mental status and
leg. a. Encourage the client to perform pursed Rationale: The significant effect of dehydration
lip breathing. nitroglycerin is vasodilation and decreased Rationale: Fever, chills, hemortysis, dyspnea,
97. An elderly client is admitted to the nursing home b. Check the client’s temperature. venous return, so the heart does not have to cough, and pleuritic chest pain are the
setting. The client is occasionally confused and c. Assess the client’s potassium level. work hard. common symptoms of pneumonia, but elderly
her gait is often unsteady. Which of the d. Increase the client’s oxygen flow rate. 5. Answer: (A) Call for help and note the time. clients may first appear with only an altered
following actions, if taken by the nurse, is most Rationale: Having established, by stimulating lentil status and dehydration due to a blunted
appropriate? the client, that the client is unconscious rather immune response.
a. Ask the woman’s family to provide than sleep, the nurse should immediately call 12. Answer: (B) Chills, fever, night sweats, and
personal items such as photos or for help. This may be done by dialing the hemoptysis
mementos. operator from the client’s phone and giving Rationale: Typical signs and symptoms are
b. Select a room with a bed by the door so the hospital code for cardiac arrest and the chills, fever, night sweats, and hemoptysis.
the woman can look down the hall. client’s room number to the operator, of if the Chest pain may be present from coughing, but
c. Suggest the woman eat her meals in the phone is not available, by pulling the isn’t usual. Clients with TB typically have low-
room with her roommate. emergency call button. Noting the time is grade fevers, not higher than 102°F (38.9°C).
d. Encourage the woman to ambulate in important baseline information for cardiac Nausea, headache, and photophobia aren’t
the halls twice a day. arrest procedure usual TB symptoms.
6. Answer: (C) Make sure that the client takes 13. Answer:(A) Acute asthma
98. Nurse Evangeline teaches an elderly client how food and medications at prescribed intervals. Rationale: Based on the client’s history and
to use a standard aluminum walker. Which of Rationale: Food and drug therapy will prevent symptoms, acute asthma is the most likely
the following behaviors, if demonstrated by the the accumulation of hydrochloric acid, or will diagnosis. He’s unlikely to have bronchial
client, indicates that the nurse’s teaching was neutralize and buffer the acid that does pneumonia without a productive cough and
effective? accumulate. fever and he’s too young to have developed
a. The client slowly pushes the walker 7. Answer: (B) Continue treatment as ordered. (COPD) and emphysema.
forward 12 inches, then takes small Rationale: The effects of heparin are 14. Answer: (B) Respiratory arrest
steps forward while leaning on the monitored by the PTT is normally 30 to 45 Rationale: Narcotics can cause respiratory
walker. seconds; the therapeutic level is 1.5 to 2 times arrest if given in large quantities. It’s unlikely
b. The client lifts the walker, moves it the normal level. the client will have asthma attack or a seizure
forward 10 inches, and then takes 8. Answer: (B) In the operating room. or wake up on his own.
several small steps forward. Rationale: The stoma drainage bag is applied 15. Answer: (D) Decreased vital capacity
c. The client supports his weight on the in the operating room. Drainage from the Rationale: Reduction in vital capacity is a
walker while advancing it forward, then ileostomy contains secretions that are rich in normal physiologic change includes decreased
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elastic recoil of the lungs, fewer functional activity and rest. Many clients with apneas periods. Biot’s respirations are rapid, 33. Answer: (B) Current health promotion
capillaries in the alveoli, and an increased in hyperthyroidism are hyperactive and complain deep breathing with abrupt pauses between activities
residual volume. of feeling very warm. each breath, and equal depth between each Rationale: Recognizing an individual’s positive
16. Answer: (C) Presence of premature ventricular 22. Answer: (B) Increase his activity level. breath. Kussmaul’s respirationa are rapid, health measures is very useful. General health
contractions (PVCs) on a cardiac monitor. Rationale: The client should be encouraged to deep breathing without pauses. Tachypnea is in the previous 10 years is important,
Rationale: Lidocaine drips are commonly used increase his activity level. aintaining an ideal shallow breathing with increased respiratory however, the current activities of an 84 year
to treat clients whose arrhythmias haven’t weight; following a low-cholesterol, low rate. old client are most significant in planning care.
been controlled with oral medication and who sodium diet; and avoiding stress are all 28. Answer: (B) Fine crackles Family history of disease for a client in later
are having PVCs that are visible on the cardiac important factors in decreasing the risk of Rationale: Fine crackles are caused by fluid in years is of minor significance. Marital status
monitor. SaO2, blood pressure, and ICP are atherosclerosis. the alveoli and commonly occur in clients with information may be important for discharge
important factors but aren’t as significant as 23. Answer: (A) Laminectomy heart failure. Tracheal breath sounds are planning but is not as significant for
PVCs in the situation. Rationale: The client who has had spinal auscultated over the trachea. Coarse crackles addressing the immediate medical problem.
17. Answer: (B) Avoid foods high in vitamin K surgery, such as laminectomy, must be log are caused by secretion accumulation in the 34. Answer: (C) Place the client in a side lying
Rationale: The client should avoid consuming rolled to keep the spinal column straight when airways. Friction rubs occur with pleural position, with the head of the bed lowered.
large amounts of vitamin K because vitamin K turning. Thoracotomy and cystectomy may inflammation. Rationale: The client should be positioned in a
can interfere with anticoagulation. The client turn themselves or may be assisted into a 29. Answer: (B) The airways are so swollen that no side-lying position with the head of the bed
may need to report diarrhea, but isn’t effect comfortable position. Under normal air cannot get through lowered to prevent aspiration. A small amount
of taking an anticoagulant. An electric razor- circumstances, hemorrhoidectomy is an Rationale: During an acute attack, wheezing of toothpaste should be used and the mouth
not a straight razor-should be used to prevent outpatient procedure, and the client may may stop and breath sounds become swabbed or suctioned to remove pooled
cuts that cause bleeding. Aspirin may increase resume normal activities immediately after inaudible because the airways are so swollen secretions. Lemon glycerin can be drying if
the risk of bleeding; acetaminophen should be surgery. that air can’t get through. If the attack is over used for extended periods. Brushing the teeth
used to pain relief. 24. Answer: (D) Avoiding straining during bowel and swelling has decreased, there would be with the client lying supine may lead to
18. Answer: (C) Clipping the hair in the area movement or bending at the waist. no more wheezing and less emergent concern. aspiration. Hydrogen peroxide is caustic to
Rationale: Hair can be a source of infection Rationale: The client should avoid straining, Crackles do not replace wheezes during an tissues and should not be used.
and should be removed by clipping. Shaving lifting heavy objects, and coughing harshly acute asthma attack. 35. Answer: (C) Pneumonia
the area can cause skin abrasions and because these activities increase intraocular 30. Answer: (D) Place the client on his side, Rationale: Fever productive cough and
depilatories can irritate the skin. pressure. Typically, the client is instructed to remove dangerous objects, and protect his pleuritic chest pain are common signs and
19. Answer: (A) Bone fracture avoid lifting objects weighing more than 15 lb head. symptoms of pneumonia. The client with
Rationale: Bone fracture is a major (7kg) – not 5lb. instruct the client when lying Rationale: During the active seizure phase, ARDS has dyspnea and hypoxia with
complication of osteoporosis that results in bed to lie on either the side or back. The initiate precautions by placing the client on his worsening hypoxia over time, if not treated
when loss of calcium and phosphate increased client should avoid bright light by wearing side, removing dangerous objects, and aggressively. Pleuritic chest pain varies with
the fragility of bones. Estrogen deficiencies sunglasses. protecting his head from injury. A bite block respiration, unlike the constant chest pain
result from menopause-not osteoporosis. 25. Answer: (D) Before age 20. should never be inserted during the active during an MI; so this client most likely isn’t
Calcium and vitamin D supplements may be Rationale: Testicular cancer commonly occurs seizure phase. Insertion can break the teeth having an MI. the client with TB typically has a
used to support normal bone metabolism, But in men between ages 20 and 30. A male client and lead to aspiration. cough producing blood-tinged sputum. A
a negative calcium balance isn’t a should be taught how to perform testicular 31. Answer: (B) Kinked or obstructed chest tube sputum culture should be obtained to confirm
complication of osteoporosis. Dowager’s self- examination before age 20, preferably Rationales: Kinking and blockage of the chest the nurse’s suspicions.
hump results from bone fractures. It develops when he enters his teens. tube is a common cause of a tension 36. Answer: (C) A 43-yesr-old homeless man with
when repeated vertebral fractures increase 26. Answer: (B) Place a saline-soaked sterile pneumothorax. Infection and excessive a history of alcoholism
spinal curvature. dressing on the wound. drainage won’t cause a tension Rationale: Clients who are economically
20. Answer: (C) Changes from previous Rationale: The nurse should first place saline- pneumothorax. Excessive water won’t affect disadvantaged, malnourished, and have
examinations. soaked sterile dressings on the open wound to the chest tube drainage. reduced immunity, such as a client with a
Rationale: Women are instructed to examine prevent tissue drying and possible infection. 32. Answer: (D) Stay with him but not intervene at history of alcoholism, are at extremely high
themselves to discover changes that have Then the nurse should call the physician and this time. risk for developing TB. A high school student,
occurred in the breast. Only a physician can take the client’s vital signs. The dehiscence Rationale: If the client is coughing, he should day- care worker, and businessman probably
diagnose lumps that are cancerous, areas of needs to be surgically closed, so the nurse be able to dislodge the object or cause a have a much low risk of contracting TB.
thickness or fullness that signal the presence should never try to close it. complete obstruction. If complete obstruction 37. Answer: (C ) To determine the extent of
of a malignancy, or masses that are fibrocystic 27. Answer: (A) A progressively deeper breaths occurs, the nurse should perform the lesions
as opposed to malignant. followed by shallower breaths with apneic abdominal thrust maneuver with the client Rationale: If the lesions are large enough, the
21. Answer: (C) Balance the client’s periods of periods. standing. If the client is unconscious, she chest X-ray will show their presence in the
activity and rest. Rationale: Cheyne-Strokes respirations are should lay him down. A nurse should never lungs. Sputum culture confirms the diagnosis.
Rationale: A client with hyperthyroidism breaths that become progressively deeper leave a choking client alone. There can be false-positive and false-negative
needs to be encouraged to balance periods of fallowed by shallower respirations with
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skin test results. A chest X-ray can’t determine fibrillation and is receiving L.V. dilitiazem regional lymph nodes, and no evidence of 54. Answer: (D) "Remain supine for the time
if this is a primary or secondary infection. (Cardizem) distant metastasis is classified as T0, N0, M0. If specified by the physician." Rationale: The
38. Answer: (B) Bronchodilators Rationale: The client with atrial fibrillation has the tumor and regional lymph nodes can't be nurse should instruct the client to remain
Rationale: Bronchodilators are the first line of the greatest potential to become unstable and assessed and no evidence of metastasis exists, supine for the time specified by the physician.
treatment for asthma because broncho- is on L.V. medication that requires close the lesion is classified as TX, NX, M0. A Local anesthetics used in a subarachnoid block
constriction is the cause of reduced airflow. monitoring. After assessing this client, the progressive increase in tumor size, no don't alter the gag reflex. No interactions
Beta- adrenergic blockers aren’t used to treat nurse should assess the client with demonstrable metastasis of the regional between local anesthetics and food occur.
asthma and can cause broncho- constriction. thrombophlebitis who is receiving a heparin lymph nodes, and ascending degrees of Local anesthetics don't cause hematuria.
Inhaled oral steroids may be given to reduce infusion, and then the 58- year-old client distant metastasis is classified as T1, T2, T3, or 55. Answer: (C) Sigmoidoscopy
the inflammation but aren’t used for admitted 2 days ago with heart failure (his T4; N0; and M1, M2, or M3. Rationale: Used to visualize the lower GI tract,
emergency relief. signs and symptoms are resolving and don’t 50. Answer: (D) "Keep the stoma moist." sigmoidoscopy and proctoscopy aid in the
39. Answer: (C) Chronic obstructive bronchitis require immediate attention). The lowest Rationale: The nurse should instruct the client detection of two-thirds of all colorectal
Rationale: Because of this extensive smoking priority is the 89-year-old with end-stage to keep the stoma moist, such as by applying a cancers. Stool Hematest detects blood, which
history and symptoms the client most likely right-sided heart failure, who requires time- thin layer of petroleum jelly around the edges, is a sign of colorectal cancer; however, the
has chronic obstructive bronchitis. Client with consuming supportive measures. because a dry stoma may become irritated. test doesn't confirm the diagnosis. CEA may
ARDS have acute symptoms of hypoxia and 46. Answer: (C) Cocaine The nurse should recommend placing a stoma be elevated in colorectal cancer but isn't
typically need large amounts of oxygen. Rationale: Because of the client’s age and bib over the stoma to filter and warm air considered a confirming test. An abdominal CT
Clients with asthma and emphysema tend not negative medical history, the nurse should before it enters the stoma. The client should scan is used to stage the presence of
to have chronic cough or peripheral edema. question her about cocaine use. Cocaine begin performing stoma care without colorectal cancer.
40. Answer: (A) The patient is under local increases myocardial oxygen consumption and assistance as soon as possible to gain 56. Answer: (B) A fixed nodular mass with
anesthesia during the procedure Rationale: can cause coronary artery spasm, leading to independence in self-care activities. dimpling of the overlying skin
Before the procedure, the patient is tachycardia, ventricular fibrillation, myocardial 51. Answer: (B) Lung cancer Rationale: A fixed nodular mass with dimpling
administered with drugs that would help to ischemia, and myocardial infarction. Rationale: Lung cancer is the most deadly type of the overlying skin is common during late
prevent infection and rejection of the Barbiturate overdose may trigger respiratory of cancer in both women and men. Breast stages of breast cancer. Many women have
transplanted cells such as antibiotics, depression and slow pulse. Opioids can cause cancer ranks second in women, followed (in slightly asymmetrical breasts. Bloody nipple
cytotoxic, and corticosteroids. During the marked respiratory depression, while descending order) by colon and rectal cancer, discharge is a sign of intraductal papilloma, a
transplant, the patient is placed under general benzodiazepines can cause drowsiness and pancreatic cancer, ovarian cancer, uterine benign condition. Multiple firm, round, freely
anesthesia. confusion. cancer, lymphoma, leukemia, liver cancer, movable masses that change with the
41. Answer: (D) Raise the side rails 47. Answer: (B) Nonmobile mass with irregular brain cancer, stomach cancer, and multiple menstrual cycle indicate fibrocystic breasts, a
Rationale: A patient who is disoriented is at edges myeloma. benign condition.
risk of falling out of bed. The initial action of Rationale: Breast cancer tumors are fixed, 52. Answer: (A) miosis, partial eyelid ptosis, and 57. Answer: (A) Liver
the nurse should be raising the side rails to hard, and poorly delineated with irregular anhidrosis on the affected side of the face. Rationale: The liver is one of the five most
ensure patients safety. edges. A mobile mass that is soft and easily Rationale: Horner's syndrome, which occurs common cancer metastasis sites. The others
42. Answer: (A) Crowd red blood cells delineated is most often a fluid-filled benign when a lung tumor invades the ribs and are the lymph nodes, lung, bone, and brain.
Rationale: The excessive production of white cyst. Axillary lymph nodes may or may not be affects the sympathetic nerve ganglia, is The colon, reproductive tract, and WBCs are
blood cells crowd out red blood cells palpable on initial detection of a cancerous characterized by miosis, partial eyelid ptosis, occasional metastasis sites.
production which causes anemia to occur. mass. Nipple retraction — not eversion — and anhidrosis on the affected side of the 58. Answer: (D) The client wears a watch and
43. Answer: (B) Leukocytosis may be a sign of cancer. face. Chest pain, dyspnea, cough, weight loss, wedding band.
Rationale: Chronic Lymphocytic leukemia (CLL) 48. Answer: (C) Radiation and fever are associated with pleural tumors. Rationale: During an MRI, the client should
is characterized by increased production of Rationale: The usual treatment for vaginal Arm and shoulder pain and atrophy of the arm wear no metal objects, such as jewelry,
leukocytes and lymphocytes resulting in cancer is external or intravaginal radiation and hand muscles on the affected side suggest because the strong magnetic field can pull on
leukocytosis, and proliferation of these cells therapy. Less often, surgery is performed. Pancoast's tumor, a lung tumor involving the them, causing injury to the client and (if they
within the bone marrow, spleen and liver. Chemotherapy typically is prescribed only if first thoracic and eighth cervical nerves within fly off) to others. The client must lie still
44. Answer: (A) Explain the risks of not having the vaginal cancer is diagnosed in an early stage, the brachial plexus. Hoarseness in a client during the MRI but can talk to those
surgery which is rare. Immunotherapy isn't used to with lung cancer suggests that the tumor has performing the test by way of the microphone
Rationale: The best initial response is to treat vaginal cancer. extended to the recurrent laryngeal nerve; inside the scanner tunnel. The client should
explain the risks of not having the surgery. If 49. Answer: (B) Carcinoma in situ, no abnormal dysphagia suggests that the lung tumor is hear thumping sounds, which are caused by
the client understands the risks but still regional lymph nodes, and no evidence of compressing the esophagus. the sound waves thumping on the magnetic
refuses the nurse should notify the physician distant metastasis 53. 53. Answer: (A) prostate-specific antigen, field.
and the nurse supervisor and then record the Rationale: TIS, N0, M0 denotes carcinoma in which is used to screen for prostate cancer. 59. Answer: (C) The recommended daily
client’s refusal in the nurses’ notes. situ, no abnormal regional lymph nodes, and Rationale: PSA stands for prostate-specific allowance of calcium may be found in a wide
45. Answer: (D) The 75-year-old client who was no evidence of distant metastasis. No antigen, which is used to screen for prostate variety of foods.
admitted 1 hour ago with new-onset atrial evidence of primary tumor, no abnormal cancer. The other answers are incorrect.
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Rationale: Premenopausal women require more likely to occur in the lower extremities. potassium and hydrogen ions. The pancreas is at greatest risk for hypoglycemia from 3
1,000 mg of calcium per day. Postmenopausal A stroke isn’t linked to protein loss. mainly secretes hormones involved in fuel p.m. to 7 p.m.
women require 1,500 mg per day. It's often, 64. Answer: (B) It appears on the distal metabolism. The adrenal medulla secretes the 75. Answer: (A) Glucocorticoids and androgens
though not always, possible to get the interphalangeal joint catecholamines — epinephrine and Rationale: The adrenal glands have two
recommended daily requirement in the foods Rationale: Heberden’s nodes appear on the norepinephrine. The parathyroids secrete divisions, the cortex and medulla. The cortex
we eat. Supplements are available but not distal interphalageal joint on both men and parathyroid hormone. produces three types of hormones:
always necessary. Osteoporosis doesn't show women. Bouchard’s node appears on the 70. Answer: (C) They debride the wound and glucocorticoids, mineralocorticoids, and
up on ordinary X-rays until 30% of the bone dorsolateral aspect of the proximal promote healing by secondary intention androgens. The medulla produces
loss has occurred. Bone densitometry can interphalangeal joint. Rationale: For this client, wet-to-dry dressings catecholamines— epinephrine and
detect bone loss of 3% or less. This test is 65. Answer: (B) Osteoarthritis is a localized are most appropriate because they clean the norepinephrine.
sometimes recommended routinely for disease rheumatoid arthritis is systemic foot ulcer by debriding exudate and necrotic 76. Answer: (A) Hypocalcemia
women over 35 who are at risk. Strenuous Rationale: Osteoarthritis is a localized disease, tissue, thus promoting healing by secondary Rationale: Hypocalcemia may follow thyroid
exercise won't cause fractures. rheumatoid arthritis is systemic. Osteoarthritis intention. Moist, transparent dressings surgery if the parathyroid glands were
60. Answer: (C) Joint flexion of less than 50% isn’t gender-specific, but rheumatoid arthritis contain exudate and provide a moist wound removed accidentally. Signs and symptoms of
Rationale: Arthroscopy is contraindicated in is. Clients have dislocations and subluxations environment. Hydrocolloid dressings prevent hypocalcemia may be delayed for up to 7 days
clients with joint flexion of less than 50% in both disorders. the entrance of microorganisms and minimize after surgery. Thyroid surgery doesn't directly
because of technical problems in inserting the 66. Answer: (C) The cane should be used on the wound discomfort. Dry sterile dressings cause serum sodium, potassium, or
instrument into the joint to see it clearly. unaffected side protect the wound from mechanical trauma magnesium abnormalities. Hyponatremia may
Other contraindications for this procedure Rationale: A cane should be used on the and promote healing. occur if the client inadvertently received too
include skin and wound infections. Joint pain unaffected side. A client with osteoarthritis 71. Answer: (A) Hyperkalemia much fluid; however, this can happen to any
may be an indication, not a contraindication, should be encouraged to ambulate with a Rationale: In adrenal insufficiency, the client surgical client receiving I.V. fluid therapy, not
for arthroscopy. Joint deformity and joint cane, walker, or other assistive device as has hyperkalemia due to reduced aldosterone just one recovering from thyroid surgery.
stiffness aren't contraindications for this needed; their use takes weight and stress off secretion. BUN increases as the glomerular Hyperkalemia and hypermagnesemia usually
procedure. joints. filtration rate is reduced. Hyponatremia is are associated with reduced renal excretion of
61. Answer: (D) Gouty arthritis 67. Answer: (A) a. 9 U regular insulin and 21 U caused by reduced aldosterone secretion. potassium and magnesium, not thyroid
Rationale: Gouty arthritis, a metabolic disease, neutral protamine Hagedorn (NPH). Reduced cortisol secretion leads to impaired surgery.
is characterized by urate deposits and pain in Rationale: A 70/30 insulin preparation is 70% glyconeogenesis and a reduction of glycogen 77. Answer: (D) Carcinoembryonic antigen level
the joints, especially those in the feet and NPH and 30% regular insulin. Therefore, a in the liver and muscle, causing hypoglycemia. Rationale: In clients who smoke, the level of
legs. Urate deposits don't occur in septic or correct substitution requires mixing 21 U of 72. Answer: (C) Restricting fluids carcinoembryonic antigen is elevated.
traumatic arthritis. Septic arthritis results from NPH and 9 U of regular insulin. The other Rationale: To reduce water retention in a Therefore, it can't be used as a general
bacterial invasion of a joint and leads to choices are incorrect dosages for the client with the SIADH, the nurse should indicator of cancer. However, it is helpful in
inflammation of the synovial lining. Traumatic prescribed insulin. restrict fluids. Administering fluids by any monitoring cancer treatment because the
arthritis results from blunt trauma to a joint or 68. Answer: (C) colchicines route would further increase the client's level usually falls to normal within 1 month if
ligament. Intermittent arthritis is a rare, Rationale: A disease characterized by joint already heightened fluid load. treatment is successful. An elevated acid
benign condition marked by regular, recurrent inflammation (especially in the great toe), 73. Answer: (D) glycosylated hemoglobin level. phosphatase level may indicate prostate
joint effusions, especially in the knees. gout is caused by urate crystal deposits in the Rationale: Because some of the glucose in the cancer. An elevated alkaline phosphatase level
62. Answer: (B) 30 ml/hou joints. The physician prescribes colchicine to bloodstream attaches to some of the may reflect bone metastasis. An elevated
Rationale: An infusion prepared with 25,000 reduce these deposits and thus ease joint hemoglobin and stays attached during the serum calcitonin level usually signals thyroid
units of heparin in 500 ml of saline solution inflammation. Although aspirin is used to 120-day life span of red blood cells, cancer.
yields 50 units of heparin per milliliter of reduce joint inflammation and pain in clients glycosylated hemoglobin levels provide 78. Answer: (B) Dyspnea, tachycardia, and pallor
solution. The equation is set up as 50 units with osteoarthritis and rheumatoid arthritis, it information about blood glucose levels during Rationale: Signs of iron-deficiency anemia
times X (the unknown quantity) equals 1,500 isn't indicated for gout because it has no the previous 3 months. Fasting blood glucose include dyspnea, tachycardia, and pallor as
units/hour, X equals 30 ml/hour. effect on urate crystal formation. Furosemide, and urine glucose levels only give information well as fatigue, listlessness, irritability, and
63. Answer: (B) Loss of muscle contraction a diuretic, doesn't relieve gout. Calcium about glucose levels at the point in time when headache. Night sweats, weight loss, and
decreasing venous return gluconate is used to reverse a negative they were obtained. Serum fructosamine diarrhea may signal acquired
Rationale: In clients with hemiplegia or calcium balance and relieve muscle cramps, levels provide information about blood immunodeficiency syndrome (AIDS). Nausea,
hemiparesis loss of muscle contraction not to treat gout. glucose control over the past 2 to 3 weeks. vomiting, and anorexia may be signs of
decreases venous return and may cause 69. Answer: (A) Adrenal cortex 74. Answer: (C) 4:00 pm hepatitis B. Itching, rash, and jaundice may
swelling of the affected extremity. Rationale: Excessive secretion of aldosterone Rationale: NPH is an intermediate-acting result from an allergic or hemolytic reaction.
Contractures, or bony calcifications may occur in the adrenal cortex is responsible for the insulin that peaks 8 to 12 hours after 79. Answer: (D) "I'll need to have a C-section if I
with a stroke, but don’t appear with swelling. client's hypertension. This hormone acts on administration. Because the nurse become pregnant and have a baby."
DVT may develop in clients with a stroke but is the renal tubule, where it promotes administered NPH insulin at 7 a.m., the client Rationale: The human immunodeficiency virus
reabsorption of sodium and excretion of (HIV) is transmitted from mother to child via
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the transplacental route, but a Cesarean therapy is discontinued. Aspirin doesn't lead in general; it doesn't confirm HIV infection. Rationale: Using comfort measures and
section delivery isn't necessary when the to weight gain or fine motor tremors. Large or Quantification of T-lymphocytes is a useful pillows to position the client is a non-
mother is HIV-positive. The use of birth toxic salicylate doses may cause respiratory monitoring test but isn't diagnostic for HIV. pharmacological methods of pain relief.
control will prevent the conception of a child alkalosis, not respiratory acidosis. The ELISA test detects HIV antibody particles 95. Answer: (B) Warm the dialysate solution.
who might have HIV. It's true that a mother 84. Answer: (D) Lymphocyte but may yield inaccurate results; a positive Rationale: Cold dialysate increases discomfort.
who's HIV positive can give birth to a baby Rationale: The lymphocyte provides adaptive ELISA result must be confirmed by the The solution should be warmed to body
who's HIV negative. immunity — recognition of a foreign antigen Western blot test. temperature in warmer or heating pad; don’t
80. Answer: (C) "Avoid sharing such articles as and formation of memory cells against the 88. Answer: (C) Abnormally low hematocrit (HCT) use microwave oven.
toothbrushes and razors." antigen. Adaptive immunity is mediated by B and hemoglobin (Hb) levels 96. Answer: (C) The client holds the cane with his
Rationale: The human immunodeficiency virus and T lymphocytes and can be acquired Rationale: Low preoperative HCT and Hb left hand, moves the cane forward followed
(HIV), which causes AIDS, is most actively or passively. The neutrophil is crucial levels indicate the client may require a blood by the right leg, and then moves the left leg.
concentrated in the blood. For this reason, the to phagocytosis. The basophil plays an transfusion before surgery. If the HCT and Hb Rationale: The cane acts as a support and aids
client shouldn't share personal articles that important role in the release of inflammatory levels decrease during surgery because of in weight bearing for the weaker right leg.
may be blood-contaminated, such as mediators. The monocyte functions in blood loss, the potential need for a 97. Answer: (A) Ask the woman’s family to
toothbrushes and razors, with other family phagocytosis and monokine production. transfusion increases. Possible renal failure is provide personal items such as photos or
members. HIV isn't transmitted by bathing or 85. Answer: (A) moisture replacement. indicated by elevated BUN or creatinine levels. mementos.
by eating from plates, utensils, or serving Rationale: Sjogren's syndrome is an Urine constituents aren't found in the blood. Rationale: Photos and mementos provide
dishes used by a person with AIDS. autoimmune disorder leading to progressive Coagulation is determined by the presence of visual stimulation to reduce sensory
81. Answer: (B) Pallor, tachycardia, and a sore loss of lubrication of the skin, GI tract, ears, appropriate clotting factors, not electrolytes. deprivation.
tongue nose, and vagina. Moisture replacement is the 89. Answer: (A) Platelet count, prothrombin time, 98. Answer: (B) The client lifts the walker, moves
Rationale: Pallor, tachycardia, and a sore mainstay of therapy. Though malnutrition and and partial thromboplastin time it forward 10 inches, and then takes several
tongue are all characteristic findings in electrolyte imbalance may occur as a result of Rationale: The diagnosis of DIC is based on the small steps forward.
pernicious anemia. Other clinical Sjogren's syndrome's effect on the GI tract, it results of laboratory studies of prothrombin Rationale: A walker needs to be picked up,
manifestations include anorexia; weight loss; a isn't the predominant problem. Arrhythmias time, platelet count, thrombin time, partial placed down on all legs.
smooth, beefy red tongue; a wide pulse aren't a problem associated with Sjogren's thromboplastin time, and fibrinogen level as 99. Answer: (C) Isolation from their families and
pressure; palpitations; angina; weakness; syndrome. well as client history and other assessment familiar surroundings.
fatigue; and paresthesia of the hands and feet. 86. Answer: (C) stool for Clostridium difficile test. factors. Blood glucose levels, WBC count, Rationale: Gradual loss of sight, hearing, and
Bradycardia, reduced pulse pressure, weight Rationale: Immunosuppressed clients — for calcium levels, and potassium levels aren't taste interferes with normal functioning.
gain, and double vision aren't characteristic example, clients receiving chemotherapy, — used to confirm a diagnosis of DIC. 100. Answer: (A) Encourage the client to perform
findings in pernicious anemia. are at risk for infection with C. difficile, which 90. Answer: (D) Strawberries pursed lip breathing.
82. Answer: (B) Administer epinephrine, as causes "horse barn" smelling diarrhea. Rationale: Common food allergens include Rationale: Purse lip breathing prevents the
prescribed, and prepare to intubate the client Successful treatment begins with an accurate berries, peanuts, Brazil nuts, cashews, collapse of lung unit and helps client control
if necessary. diagnosis, which includes a stool test. The shellfish, and eggs. Bread, carrots, and rate and depth of breathing.
Rationale: To reverse anaphylactic shock, the ELISA test is diagnostic for human oranges rarely cause allergic reactions.
nurse first should administer epinephrine, a immunodeficiency virus (HIV) and isn't 91. Answer: (B) A client with cast on the right leg
potent bronchodilator as prescribed. The indicated in this case. An electrolyte panel and who states, “I have a funny feeling in my right
physician is likely to order additional hemogram may be useful in the overall leg.”
medications, such as antihistamines and evaluation of a client but aren't diagnostic for Rationale: It may indicate neurovascular
corticosteroids; if these medications don't specific causes of diarrhea. A flat plate of the compromise, requires immediate assessment.
relieve the respiratory compromise associated abdomen may provide useful information 92. Answer: (D) A 62-year-old who had an
with anaphylaxis, the nurse should prepare to about bowel function but isn't indicated in the abdominal-perineal resection three days ago;
intubate the client. No antidote for penicillin case of "horse barn" smelling diarrhea. client complaints of chills.
exists; however, the nurse should continue to 87. Answer: (D) Western blot test with ELISA. Rationale: The client is at risk for peritonitis;
monitor the client's vital signs. A client who Rationale: HIV infection is detected by should be assessed for further symptoms and
remains hypotensive may need fluid analyzing blood for antibodies to HIV, which infection.
resuscitation and fluid intake and output form approximately 2 to 12 weeks after 93. Answer: (C) The client spontaneously flexes
monitoring; however, administering exposure to HIV and denote infection. The his wrist when the blood pressure is obtained.
epinephrine is the first priority. Western blot test — electrophoresis of Rationale: Carpal spasms indicate
83. Answer: (D) bilateral hearing loss. antibody proteins — is more than 98% hypocalcemia.
Rationale: Prolonged use of aspirin and other accurate in detecting HIV antibodies when 94. Answer: (D) Use comfort measures and
salicylates sometimes causes bilateral hearing used in conjunction with the ELISA. It isn't pillows to position the client.
loss of 30 to 40 decibels. Usually, this adverse specific when used alone. E-rosette
effect resolves within 2 weeks after the immunofluorescence is used to detect viruses
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TEST IV - Care of Clients with Physiologic and b. Decrease fluid intake at meal times. from a 2-story building. When assessing the d. Only ice chips and cold liquids will be
Psychosocial Alterations c. Avoid foods that in the past caused client, the nurse would be most concerned if the allowed initially.
flatus. assessment revealed:
1. Randy has undergone kidney transplant, what d. Adhere to a bland diet prior to social a. Reactive pupils 16. Nurse Tristan is caring for a male client in acute
assessment would prompt Nurse Katrina to events. b. A depressed fontanel renal failure. The nurse should expect hypertonic
suspect organ rejection? c. Bleeding from ears glucose, insulin infusions, and sodium
a. Sudden weight loss 7. Nurse Ron begins to teach a male client how to d. An elevated temperature bicarbonate to be used to treat:
b. Polyuria perform colostomy irrigations. The nurse would a. hypernatremia.
c. Hypertension evaluate that the instructions were understood 12. Nurse Sherry is teaching male client regarding b. hypokalemia.
d. Shock when the client states, “I should: his permanent artificial pacemaker. Which c. hyperkalemia.
a. Lie on my left side while instilling the information given by the nurse shows her d. hypercalcemia.
2. The immediate objective of nursing care for an irrigating solution.” knowledge deficit about the artificial cardiac
overweight, mildly hypertensive male client with b. Keep the irrigating container less than pacemaker? 17. Ms. X has just been diagnosed with condylomata
ureteral colic and hematuria is to decrease: 18 inches above the stoma.” a. take the pulse rate once a day, in the acuminata (genital warts). What information is
a. Pain c. Instill a minimum of 1200 ml of irrigating morning upon awakening appropriate to tell this client?
b. Weight solution to stimulate evacuation of the b. May be allowed to use electrical a. This condition puts her at a higher risk
c. Hematuria bowel.” appliances for cervical cancer; therefore, she should
d. Hypertension d. Insert the irrigating catheter deeper into c. Have regular follow up care have a Papanicolaou (Pap) smear
the stoma if cramping occurs during the d. May engage in contact sports annually.
3. Matilda, with hyperthyroidism is to receive procedure.” b. The most common treatment is
Lugol’s iodine solution before a subtotal 13. The nurse is ware that the most relevant metronidazole (Flagyl), which should
thyroidectomy is performed. The nurse is aware 8. Patrick is in the oliguric phase of acute tubular knowledge about oxygen administration to a eradicate the problem within 7 to 10
that this medication is given to: necrosis and is experiencing fluid and electrolyte male client with COPD is days.
a. Decrease the total basal metabolic rate. imbalances. The client is somewhat confused a. Oxygen at 1-2L/min is given to maintain c. The potential for transmission to her
b. Maintain the function of the parathyroid and complains of nausea and muscle weakness. the hypoxic stimulus for breathing. sexual partner will be eliminated if
glands. As part of the prescribed therapy to correct this b. Hypoxia stimulates the central condoms are used every time they have
c. Block the formation of thyroxine by the electrolyte imbalance, the nurse would expect chemoreceptors in the medulla that sexual intercourse.
thyroid gland. to: makes the client breath. d. The human papillomavirus (HPV), which
d. Decrease the size and vascularity of the a. Administer Kayexalate c. Oxygen is administered best using a non- causes condylomata acuminata, can't be
thyroid gland. b. Restrict foods high in protein rebreathing mask transmitted during oral sex.
c. Increase oral intake of cheese and milk. d. Blood gases are monitored using a pulse
4. Ricardo, was diagnosed with type I diabetes. The d. Administer large amounts of normal oximeter. 18. Maritess was recently diagnosed with a
nurse is aware that acute hypoglycemia also can saline via I.V. genitourinary problem and is being examined in
develop in the client who is diagnosed with: 14. Tonny has undergoes a left thoracotomy and a the emergency department. When palpating her
a. Liver disease 9. Mario has burn injury. After Forty48 hours, the partial pneumonectomy. Chest tubes are kidneys, the nurse should keep which anatomical
b. Hypertension physician orders for Mario 2 liters of IV fluid to inserted, and one-bottle water-seal drainage is fact in mind?
c. Type 2 diabetes be administered q12 h. The drop factor of the instituted in the operating room. In the a. The left kidney usually is slightly higher
d. Hyperthyroidism tubing is 10 gtt/ml. The nurse should set the postanesthesia care unit Tonny is placed in than the right one.
flow to provide: Fowler's position on either his right side or on b. The kidneys are situated just above the
5. Tracy is receiving combination chemotherapy for a. 18 gtt/min his back. The nurse is aware that this position: adrenal glands.
treatment of metastatic carcinoma. Nurse Ruby b. 28 gtt/min a. Reduce incisional pain. c. The average kidney is approximately 5
should monitor the client for the systemic side c. 32 gtt/min b. Facilitate ventilation of the left lung. cm (2") long and 2 to 3 cm (¾" to 1-1/8")
effect of: d. 36 gtt/min c. Equalize pressure in the pleural space. wide.
a. Ascites d. Increase venous return d. The kidneys lie between the 10th and
b. Nystagmus 10. Terence suffered from burn injury. Using the rule 12th thoracic vertebrae.
c. Leukopenia of nines, which has the largest percent of burns? 15. Kristine is scheduled for a bronchoscopy. When
d. Polycythemia a. Face and neck teaching Kristine what to expect afterward, the 19. Jestoni with chronic renal failure (CRF) is
b. Right upper arm and penis nurse's highest priority of information would be: admitted to the urology unit. The nurse is aware
6. Norma, with recent colostomy expresses c. Right thigh and penis a. Food and fluids will be withheld for at that the diagnostic test are consistent with CRF if
concern about the inability to control the d. Upper trunk least 2 hours. the result is:
passage of gas. Nurse Oliver should suggest that b. Warm saline gargles will be done q 2h. a. Increased pH with decreased hydrogen
the client plan to: 11. Herbert, a 45 year old construction engineer is c. Coughing and deep-breathing exercises ions.
a. Eliminate foods high in cellulose. brought to the hospital unconscious after falling will be done q2h.
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b. Increased serum levels of potassium, b. Palpate the abdomen. 29. Nurse Maria plans to administer dexamethasone 34. A 37-year-old male client was admitted to the
magnesium, and calcium. c. Change the client's position. cream to a female client who has dermatitis over coronary care unit (CCU) 2 days ago with an
c. Blood urea nitrogen (BUN) 100 mg/dl d. Insert a rectal tube. the anterior chest. How should the nurse apply acute myocardial infarction. Which of the
and serum creatinine 6.5 mg/ dl. this topical agent? following actions would breach the client
d. Uric acid analysis 3.5 mg/dl and 24. Wilfredo with a recent history of rectal bleeding a. With a circular motion, to enhance confidentiality?
phenolsulfonphthalein (PSP) excretion is being prepared for a colonoscopy. How should absorption. a. The CCU nurse gives a verbal report to
75%. the nurse Patricia position the client for this test b. With an upward motion, to increase the nurse on the telemetry unit before
initially? blood supply to the affected area transferring the client to that unit
20. Katrina has an abnormal result on a a. Lying on the right side with legs straight c. In long, even, outward, and downward b. The CCU nurse notifies the on-call
Papanicolaou test. After admitting that she read b. Lying on the left side with knees bent strokes in the direction of hair growth physician about a change in the client’s
her chart while the nurse was out of the room, c. Prone with the torso elevated d. In long, even, outward, and upward condition
Katrina asks what dysplasia means. Which d. Bent over with hands touching the floor strokes in the direction opposite hair c. The emergency department nurse calls
definition should the nurse provide? growth up the latest electrocardiogram results
a. Presence of completely undifferentiated 25. A male client with inflammatory bowel disease to check the client’s progress.
tumor cells that don't resemble cells of undergoes an ileostomy. On the first day after 30. Nurse Kate is aware that one of the following d. At the client’s request, the CCU nurse
the tissues of their origin. surgery, Nurse Oliver notes that the client's classes of medication protects the ischemic updates the client’s wife on his condition
b. Increase in the number of normal cells in stoma appears dusky. How should the nurse myocardium by blocking catecholamines and
a normal arrangement in a tissue or an interpret this finding? sympathetic nerve stimulation is: 35. A male client arriving in the emergency
organ. a. Blood supply to the stoma has been a. Beta -adrenergic blockers department is receiving cardiopulmonary
c. Replacement of one type of fully interrupted. b. Calcium channel blocker resuscitation from paramedics who are giving
differentiated cell by another in tissues b. This is a normal finding 1 day after c. Narcotics ventilations through an endotracheal (ET) tube
where the second type normally isn't surgery. d. Nitrates that they placed in the client’s home. During a
found. c. The ostomy bag should be adjusted. pause in compressions, the cardiac monitor
d. Alteration in the size, shape, and d. An intestinal obstruction has occurred. 31. A male client has jugular distention. On what shows narrow QRS complexes and a heart rate
organization of differentiated cells. position should the nurse place the head of the of beats/minute with a palpable pulse. Which of
26. Anthony suffers burns on the legs, which nursing bed to obtain the most accurate reading of the following actions should the nurse take first?
21. During a routine checkup, Nurse Mariane intervention helps prevent contractures? jugular vein distention? a. Start an L.V. line and administer
assesses a male client with acquired a. Applying knee splints a. High Fowler’s amiodarone (Cardarone), 300 mg L.V.
immunodeficiency syndrome (AIDS) for signs and b. Elevating the foot of the bed b. Raised 10 degrees over 10 minutes.
symptoms of cancer. What is the most common c. Hyperextending the client's palms c. Raised 30 degrees b. Check endotracheal tube placement.
AIDS-related cancer? d. Performing shoulder range-of-motion d. Supine position c. Obtain an arterial blood gas (ABG)
a. Squamous cell carcinoma exercises sample.
b. Multiple myeloma 32. The nurse is aware that one of the following d. Administer atropine, 1 mg L.V.
c. Leukemia 27. Nurse Ron is assessing a client admitted with classes of medications maximizes cardiac
d. Kaposi's sarcoma second- and third-degree burns on the face, performance in clients with heart failure by 36. After cardiac surgery, a client’s blood pressure
arms, and chest. Which finding indicates a increasing ventricular contractility? measures 126/80 mm Hg. Nurse Katrina
22. Ricardo is scheduled for a prostatectomy, and potential problem? a. Beta-adrenergic blockers determines that mean arterial pressure (MAP) is
the anesthesiologist plans to use a spinal a. Partial pressure of arterial oxygen b. Calcium channel blocker which of the following?
(subarachnoid) block during surgery. In the (PaO2) value of 80 mm Hg. c. Diuretics a. 46 mm Hg
operating room, the nurse positions the client b. Urine output of 20 ml/hour. d. Inotropic agents b. 80 mm Hg
according to the anesthesiologist's instructions. c. White pulmonary secretions. c. 95 mm Hg
Why does the client require special positioning d. Rectal temperature of 100.6° F (38° C). 33. A male client has a reduced serum high-density d. 90 mm Hg
for this type of anesthesia? lipoprotein (HDL) level and an elevated low-
a. To prevent confusion 28. Mr. Mendoza who has suffered a density lipoprotein (LDL) level. Which of the 37. A female client arrives at the emergency
b. To prevent seizures cerebrovascular accident (CVA) is too weak to following dietary modifications is not department with chest and stomach pain and a
c. To prevent cerebrospinal fluid (CSF) move on his own. To help the client avoid appropriate for this client? report of black tarry stool for several months.
leakage pressure ulcers, Nurse Celia should: a. Fiber intake of 25 to 30 g daily Which of the following order should the nurse
d. To prevent cardiac arrhythmias a. Turn him frequently. b. Less than 30% of calories from fat Oliver anticipate?
b. Perform passive range-of-motion (ROM) c. Cholesterol intake of less than 300 mg a. Cardiac monitor, oxygen, creatine kinase
23. A male client had a nephrectomy 2 days ago and exercises. daily and lactate dehydrogenase levels
is now complaining of abdominal pressure and c. Reduce the client's fluid intake. d. Less than 10% of calories from saturated b. Prothrombin time, partial
nausea. The first nursing action should be to: d. Encourage the client to use a footboard. fat thromboplastin time, fibrinogen and
a. Auscultate bowel sounds. fibrin split product values.
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c. Electrocardiogram, complete blood 43. The nurse is aware that the following symptom red and swollen, when the IV is touched Stacy
count, testing for occult blood, is most commonly an early indication of stage 1 49. A male client with a gunshot wound requires an shouts in pain. The first nursing action to take is:
comprehensive serum metabolic panel. Hodgkin’s disease? emergency blood transfusion. His blood type is a. Notify the physician
d. Electroencephalogram, alkaline a. Pericarditis AB negative. Which blood type would be the b. Flush the IV line with saline solution
phosphatase and aspartate b. Night sweat safest for him to receive? c. Immediately discontinue the infusion
aminotransferase levels, basic serum c. Splenomegaly a. AB Rh-positive d. Apply an ice pack to the site, followed by
metabolic panel d. Persistent hypothermia b. A Rh-positive warm compress.
c. A Rh-negative
38. Macario had coronary artery bypass graft (CABG) 44. Francis with leukemia has neutropenia. Which of d. O Rh-positive 54. The term “blue bloater” refers to a male client
surgery 3 days ago. Which of the following the following functions must frequently which of the following conditions?
conditions is suspected by the nurse when a assessed? Situation: Stacy is diagnosed with acute lymphoid a. Adult respiratory distress syndrome
decrease in platelet count from 230,000 ul to a. Blood pressure leukemia (ALL) and beginning chemotherapy. (ARDS)
5,000 ul is noted? b. Bowel sounds b. Asthma
a. Pancytopenia c. Heart sounds 50. Stacy is discharged from the hospital following c. Chronic obstructive bronchitis
b. Idiopathic thrombocytopemic purpura d. Breath sounds her chemotherapy treatments. Which statement d. Emphysema
(ITP) of Stacy’s mother indicated that she understands
c. Disseminated intravascular coagulation 45. The nurse knows that neurologic complications when she will contact the physician? 55. The term “pink puffer” refers to the female
(DIC) of multiple myeloma (MM) usually involve which a. “I should contact the physician if Stacy client with which of the following conditions?
d. Heparin-associated thrombosis and of the following body system? has difficulty in sleeping”. a. Adult respiratory distress syndrome
thrombocytopenia (HATT) a. Brain b. “I will call my doctor if Stacy has (ARDS)
b. Muscle spasm persistent vomiting and diarrhea”. b. Asthma
39. Which of the following drugs would be ordered c. Renal dysfunction c. “My physician should be called if Stacy is c. Chronic obstructive bronchitis
by the physician to improve the platelet count in d. Myocardial irritability irritable and unhappy”. d. Emphysema
a male client with idiopathic thrombocytopenic d. “Should Stacy have continued hair loss, I
purpura (ITP)? 46. Nurse Patricia is aware that the average length need to call the doctor”. 56. Jose is in danger of respiratory arrest following
a. Acetylsalicylic acid (ASA) of time from human immunodeficiency virus the administration of a narcotic analgesic. An
b. Corticosteroids (HIV) infection to the development of acquired 51. Stacy’s mother states to the nurse that it is hard arterial blood gas value is obtained. Nurse Oliver
c. Methotrezate immunodeficiency syndrome (AIDS)? to see Stacy with no hair. The best response for would expect the paco2 to be which of the
d. Vitamin K a. Less than 5 years the nurse is: following values?
b. 5 to 7 years a. “Stacy looks very nice wearing a hat”. a. 15 mm Hg
40. A female client is scheduled to receive a heart c. 10 years b. “You should not worry about her hair, b. 30 mm Hg
valve replacement with a porcine valve. Which d. More than 10 years just be glad that she is alive”. c. 40 mm Hg
of the following types of transplant is this? c. “Yes it is upsetting. But try to cover up d. 80 mm Hg
a. Allogeneic 47. An 18-year-old male client admitted with heat your feelings when you are with her or
b. Autologous stroke begins to show signs of disseminated else she may be upset”. 57. Timothy’s arterial blood gas (ABG) results are as
c. Syngeneic intravascular coagulation (DIC). Which of the d. “This is only temporary; Stacy will re- follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm
d. Xenogeneic following laboratory findings is most consistent grow new hair in 3-6 months, but may Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
with DIC? be different in texture”. represents which of the following conditions?
41. Marco falls off his bicycle and injuries his ankle. a. Low platelet count a. Metabolic acidosis
Which of the following actions shows the initial b. Elevated fibrinogen levels 52. Stacy has beginning stomatitis. To promote oral b. Metabolic alkalosis
response to the injury in the extrinsic pathway? c. Low levels of fibrin degradation products hygiene and comfort, the nurse in-charge c. Respiratory acidosis
a. Release of Calcium d. Reduced prothrombin time should: d. Respiratory alkalosis
b. Release of tissue thromboplastin a. Provide frequent mouthwash with
c. Conversion of factors XII to factor XIIa 48. Mario comes to the clinic complaining of fever, normal saline. 58. Norma has started a new drug for hypertension.
d. Conversion of factor VIII to factor VIIIa drenching night sweats, and unexplained weight b. Apply viscous Lidocaine to oral ulcers as Thirty minutes after she takes the drug, she
42. Instructions for a client with systemic lupus loss over the past 3 months. Physical needed. develops chest tightness and becomes short of
erythematosus (SLE) would include information examination reveals a single enlarged c. Use lemon glycerine swabs every 2 breath and tachypneic. She has a decreased level
about which of the following blood dyscrasias? supraclavicular lymph node. Which of the hours. of consciousness. These signs indicate which of
a. Dressler’s syndrome following is the most probable diagnosis? d. Rinse mouth with Hydrogen Peroxide. the following conditions?
b. Polycythemia a. Influenza a. Asthma attack
c. Essential thrombocytopenia b. Sickle cell anemia 53. During the administration of chemotherapy b. Pulmonary embolism
d. Von Willebrand’s disease c. Leukemia agents, Nurse Oliver observed that the IV site is c. Respiratory failure
d. Hodgkin’s disease d. Rheumatoid arthritis
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decreased RBC count, decreased WBC 69. Nurse Nikki knows that laboratory results 73. JP has been diagnosed with gout and wants to
Situation: Mr. Gonzales was admitted to the hospital count. supports the diagnosis of systemic lupus know why colchicine is used in the treatment of
with ascites and jaundice. To rule out cirrhosis of the d. Intermitted lower back pain, decreased erythematosus (SLE) is: gout. Which of the following actions of
liver: blood pressure, decreased RBC count, a. Elavated serum complement level colchicines explains why it’s effective for gout?
increased WBC count. b. Thrombocytosis, elevated sedimentation a. Replaces estrogen
59. Which laboratory test indicates liver cirrhosis? rate b. Decreases infection
a. Decreased red blood cell count 64. After undergoing a cardiac catheterization, Tracy c. Pancytopenia, elevated antinuclear c. Decreases inflammation
b. Decreased serum acid phosphate level has a large puddle of blood under his buttocks. antibody (ANA) titer d. Decreases bone demineralization
c. Elevated white blood cell count Which of the following steps should the nurse d. Leukocysis, elevated blood urea nitrogen
d. Elevated serum aminotransferase take first? (BUN) and creatinine levels 74. Norma asks for information about osteoarthritis.
a. Call for help. Which of the following statements about
60. 60.The biopsy of Mr. Gonzales confirms the b. Obtain vital signs 70. Arnold, a 19-year-old client with a mild osteoarthritis is correct?
diagnosis of cirrhosis. Mr. Gonzales is at c. Ask the client to “lift up” concussion is discharged from the emergency a. Osteoarthritis is rarely debilitating
increased risk for excessive bleeding primarily d. Apply gloves and assess the groin site department. Before discharge, he complains of a b. Osteoarthritis is a rare form of arthritis
because of: headache. When offered acetaminophen, his c. Osteoarthritis is the most common form
a. Impaired clotting mechanism 65. Which of the following treatment is a suitable mother tells the nurse the headache is severe of arthritis
b. Varix formation surgical intervention for a client with unstable and she would like her son to have something d. Osteoarthritis afflicts people over 60
c. Inadequate nutrition angina? stronger. Which of the following responses by
d. Trauma of invasive procedure a. Cardiac catheterization the nurse is appropriate? 75. Ruby is receiving thyroid replacement therapy
b. Echocardiogram a. “Your son had a mild concussion, develops the flu and forgets to take her thyroid
61. Mr. Gonzales develops hepatic encephalopathy. c. Nitroglycerin acetaminophen is strong enough.” replacement medicine. The nurse understands
Which clinical manifestation is most common d. Percutaneous transluminal coronary b. “Aspirin is avoided because of the that skipping this medication will put the client
with this condition? angioplasty (PTCA) danger of Reye’s syndrome in children or at risk for developing which of the following life-
a. Increased urine output young adults.” threatening complications?
b. Altered level of consciousness 66. The nurse is aware that the following terms used c. “Narcotics are avoided after a head a. Exophthalmos
c. Decreased tendon reflex to describe reduced cardiac output and injury because they may hide a b. Thyroid storm
d. Hypotension perfusion impairment due to ineffective worsening condition.” c. Myxedema coma
pumping of the heart is: d. Stronger medications may lead to d. Tibial myxedema
62. When Mr. Gonzales regained consciousness, the a. Anaphylactic shock vomiting, which increases the
physician orders 50 ml of Lactose p.o. every 2 b. Cardiogenic shock intracarnial pressure (ICP).” 76. Nurse Sugar is assessing a client with Cushing's
hours. Mr. Gozales develops diarrhea. The nurse c. Distributive shock 71. When evaluating an arterial blood gas from a syndrome. Which observation should the nurse
best action would be: d. Myocardial infarction (MI) male client with a subdural hematoma, the report to the physician immediately?
a. “I’ll see if your physician is in the nurse notes the Paco2 is 30 mm Hg. Which of a. Pitting edema of the legs
hospital”. 67. A client with hypertension asks the nurse which the following responses best describes the b. An irregular apical pulse
b. “Maybe you’re reacting to the drug; I factors can cause blood pressure to drop to result? c. Dry mucous membranes
will withhold the next dose”. normal levels? a. Appropriate; lowering carbon dioxide d. Frequent urination
c. “I’ll lower the dosage as ordered so the a. Kidneys’ excretion to sodium only. (CO2) reduces intracranial pressure (ICP)
drug causes only 2 to 4 stools a day”. b. Kidneys’ retention of sodium and water b. Emergent; the client is poorly 77. Cyrill with severe head trauma sustained in a car
d. “Frequently, bowel movements are c. Kidneys’ excretion of sodium and water oxygenated accident is admitted to the intensive care unit.
needed to reduce sodium level”. d. Kidneys’ retention of sodium and c. Normal Thirty-six hours later, the client's urine output
excretion of water d. Significant; the client has alveolar suddenly rises above 200 ml/hour, leading the
63. Which of the following groups of symptoms hypoventilation nurse to suspect diabetes insipidus. Which
indicates a ruptured abdominal aortic 68. Nurse Rose is aware that the statement that laboratory findings support the nurse's suspicion
aneurysm? best explains why furosemide (Lasix) is 72. When prioritizing care, which of the following of diabetes insipidus?
a. Lower back pain, increased blood administered to treat hypertension is: clients should the nurse Olivia assess first? a. Above-normal urine and serum
pressure, decreased red blood cell (RBC) a. It dilates peripheral blood vessels. a. A 17-year-old client’s 24-hours osmolality levels
count, increased white blood (WBC) b. It decreases sympathetic postappendectomy b. Below-normal urine and serum
count. cardioacceleration. b. A 33-year-old client with a recent osmolality levels
b. Severe lower back pain, decreased blood c. It inhibits the angiotensin-coverting diagnosis of Guillain-Barre syndrome c. Above-normal urine osmolality level,
pressure, decreased RBC count, enzymes c. A 50-year-old client 3 days below-normal serum osmolality level
increased WBC count. d. It inhibits reabsorption of sodium and postmyocardial infarction d. Below-normal urine osmolality level,
c. Severe lower back pain, decreased blood water in the loop of Henle. d. A 50-year-old client with diverticulitis above-normal serum osmolality level
pressure, decreased RBC count,
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78. Jomari is diagnosed with hyperosmolar d. Low corticotropin and low cortisol levels a. "Inject insulin into healthy tissue with a. Adult respiratory distress syndrome
hyperglycemic nonketotic syndrome (HHNS) is large blood vessels and nerves." (ARDS)
stabilized and prepared for discharge. When 82. A male client is scheduled for a transsphenoidal b. "Rotate injection sites within the same b. Atelectasis
preparing the client for discharge and home hypophysectomy to remove a pituitary tumor. anatomic region, not among different c. Bronchitis
management, which of the following statements Preoperatively, the nurse should assess for regions." d. Pneumonia
indicates that the client understands her potential complications by doing which of the c. "Administer insulin into areas of scar
condition and how to control it? following? tissue or hypotrophy whenever 91. A 67-year-old client develops acute shortness of
a. "I can avoid getting sick by not becoming a. Testing for ketones in the urine possible." breath and progressive hypoxia requiring right
dehydrated and by paying attention to b. Testing urine specific gravity d. "Administer insulin into sites above femur. The hypoxia was probably caused by
my need to urinate, drink, or eat more c. Checking temperature every 4 hours muscles that you plan to exercise heavily which of the following conditions?
than usual." d. Performing capillary glucose testing later that day." a. Asthma attack
b. "If I experience trembling, weakness, every 4 hours b. Atelectasis
and headache, I should drink a glass of 86. Nurse Sarah expects to note an elevated serum c. Bronchitis
soda that contains sugar." 83. Capillary glucose monitoring is being performed glucose level in a client with hyperosmolar d. Fat embolism
c. "I will have to monitor my blood glucose every 4 hours for a client diagnosed with hyperglycemic nonketotic syndrome (HHNS).
level closely and notify the physician if diabetic ketoacidosis. Insulin is administered Which other laboratory finding should the nurse 92. A client with shortness of breath has decreased
it's constantly elevated." using a scale of regular insulin according to anticipate? to absent breath sounds on the right side, from
d. "If I begin to feel especially hungry and glucose results. At 2 p.m., the client has a a. Elevated serum acetone level the apex to the base. Which of the following
thirsty, I'll eat a snack high in capillary glucose level of 250 mg/dl for which he b. Serum ketone bodies conditions would best explain this?
carbohydrates." receives 8 U of regular insulin. Nurse Mariner c. Serum alkalosis a. Acute asthma
should expect the dose's: d. Below-normal serum potassium level b. Chronic bronchitis
79. A 66-year-old client has been complaining of a. onset to be at 2 p.m. and its peak to be c. Pneumonia
sleeping more, increased urination, anorexia, at 3 p.m. 87. For a client with Graves' disease, which nursing d. Spontaneous pneumothorax
weakness, irritability, depression, and bone pain b. onset to be at 2:15 p.m. and its peak to intervention promotes comfort?
that interferes with her going outdoors. Based be at 3 p.m. a. Restricting intake of oral fluids 93. A 62-year-old male client was in a motor vehicle
on these assessment findings, the nurse would c. onset to be at 2:30 p.m. and its peak to b. Placing extra blankets on the client's bed accident as an unrestrained driver. He’s now in
suspect which of the following disorders? be at 4 p.m. c. Limiting intake of high-carbohydrate the emergency department complaining of
a. Diabetes mellitus d. onset to be at 4 p.m. and its peak to be foods difficulty of breathing and chest pain. On
b. Diabetes insipidus at 6 p.m. d. Maintaining room temperature in the auscultation of his lung field, no breath sounds
c. Hypoparathyroidism low-normal range are present in the upper lobe. This client may
d. Hyperparathyroidism 84. The physician orders laboratory tests to confirm have which of the following conditions?
hyperthyroidism in a female client with classic 88. Patrick is treated in the emergency department a. Bronchitis
80. Nurse Lourdes is teaching a client recovering signs and symptoms of this disorder. Which test for a Colles' fracture sustained during a fall. b. Pneumonia
from addisonian crisis about the need to take result would confirm the diagnosis? What is a Colles' fracture? c. Pneumothorax
fludrocortisone acetate and hydrocortisone at a. No increase in the thyroid-stimulating a. Fracture of the distal radius d. Tuberculosis (TB)
home. Which statement by the client indicates hormone (TSH) level after 30 minutes b. Fracture of the olecranon
an understanding of the instructions? during the TSH stimulation test c. Fracture of the humerus 94. If a client requires a pneumonectomy, what fills
a. "I'll take my hydrocortisone in the late b. A decreased TSH level d. Fracture of the carpal scaphoid the area of the thoracic cavity?
afternoon, before dinner." c. An increase in the TSH level after 30 a. The space remains filled with air only
b. "I'll take all of my hydrocortisone in the minutes during the TSH stimulation test 89. Cleo is diagnosed with osteoporosis. Which b. The surgeon fills the space with a gel
morning, right after I wake up." d. Below-normal levels of serum electrolytes are involved in the development of c. Serous fluids fills the space and
c. "I'll take two-thirds of the dose when I triiodothyronine (T3) and serum this disorder? consolidates the region
wake up and one-third in the late thyroxine (T4) as detected by a. Calcium and sodium d. The tissue from the other lung grows
afternoon." radioimmunoassay b. Calcium and phosphorous over to the other side
d. "I'll take the entire dose at bedtime." c. Phosphorous and potassium
85. Rico with diabetes mellitus must learn how to d. Potassium and sodium 95. Hemoptysis may be present in the client with a
81. Which of the following laboratory test results self-administer insulin. The physician has pulmonary embolism because of which of the
would suggest to the nurse Len that a client has prescribed 10 U of U-100 regular insulin and 35 90. Johnny a firefighter was involved in following reasons?
a corticotropin-secreting pituitary adenoma? U of U-100 isophane insulin suspension (NPH) to extinguishing a house fire and is being treated to a. Alveolar damage in the infracted area
a. High corticotropin and low cortisol levels be taken before breakfast. When teaching the smoke inhalation. He develops severe hypoxia b. Involvement of major blood vessels in
b. Low corticotropin and high cortisol levels client how to select and rotate insulin injection 48 hours after the incident, requiring intubation the occluded area
c. High corticotropin and high cortisol sites, the nurse should provide which and mechanical ventilation. He most likely has c. Loss of lung parenchyma
levels instruction? developed which of the following conditions? d. Loss of lung tissue
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c. “Every four hours I should remove the Answers and Rationale – Care of Clients with 10. Answer: (D) Upper trunk
96. Aldo with a massive pulmonary embolism will stockings for a half hour.” Physiologic and Psychosocial Alterations Rationale: The percentage designated for
have an arterial blood gas analysis performed to d. “I should put on the stockings before each burned part of the body using the
determine the extent of hypoxia. The acid-base getting out of bed in the morning.” 1. Answer: (C) Hypertension rule of nines: Head and neck 9%; Right
disorder that may be present is? Rationale: Hypertension, along with fever, upper extremity 9%; Left upper extremity
a. Metabolic acidosis and tenderness over the grafted kidney, 9%; Anterior trunk 18%; Posterior trunk
b. Metabolic alkalosis reflects acute rejection. 18%; Right lower extremity 18%; Left
c. Respiratory acidosis 2. Answer: (A) Pain lower extremity 18%; Perineum 1%.
d. Respiratory alkalosis Rationale: Sharp, severe pain (renal colic) 11. Answer: (C) Bleeding from ears
radiating toward the genitalia and thigh is Rationale: The nurse needs to perform a
97. After a motor vehicle accident, Armand an 22- caused by uretheral distention and thorough assessment that could indicate
year-old client is admitted with a pneumothorax. smooth muscle spasm; relief form pain is alterations in cerebral function, increased
The surgeon inserts a chest tube and attaches it the priority. intracranial pressures, fractures and
to a chest drainage system. Bubbling soon 3. Answer: (D) Decrease the size and bleeding. Bleeding from the ears occurs
appears in the water seal chamber. Which of the vascularity of the thyroid gland. only with basal skull fractures that can
following is the most likely cause of the Rationale: Lugol’s solution provides easily contribute to increased intracranial
bubbling? iodine, which aids in decreasing the pressure and brain herniation.
a. Air leak vascularity of the thyroid gland, which 12. Answer: (D) may engage in contact sports
b. Adequate suction limits the risk of hemorrhage when Rationale: The client should be advised by
c. Inadequate suction surgery is performed. the nurse to avoid contact sports. This will
d. Kinked chest tube 4. Answer: (A) Liver Disease prevent trauma to the area of the
Rationale: The client with liver disease has pacemaker generator.
98. Nurse Michelle calculates the IV flow rate for a a decreased ability to metabolize 13. Answer: (A) Oxygen at 1-2L/min is given to
postoperative client. The client receives 3,000 ml carbohydrates because of a decreased maintain the hypoxic stimulus for
of Ringer’s lactate solution IV to run over 24 ability to form glycogen (glycogenesis) and breathing.
hours. The IV infusion set has a drop factor of 10 to form glucose from glycogen. Rationale: COPD causes a chronic CO2
drops per milliliter. The nurse should regulate 5. Answer: (C) Leukopenia retention that renders the medulla
the client’s IV to deliver how many drops per Rationale: Leukopenia, a reduction in insensitive to the CO2 stimulation for
minute? WBCs, is a systemic effect of breathing. The hypoxic state of the client
a. 18 chemotherapy as a result of then becomes the stimulus for breathing.
b. 21 myelosuppression. Giving the client oxygen in low
c. 35 6. Answer: (C) Avoid foods that in the past concentrations will maintain the client’s
d. 40 caused flatus. hypoxic drive.
Rationale: Foods that bothered a person 14. Answer: (B) Facilitate ventilation of the
99. Mickey, a 6-year-old child with a congenital preoperatively will continue to do so after left lung.
heart disorder is admitted with congestive heart a colostomy. Rationale: Since only a partial
failure. Digoxin (lanoxin) 0.12 mg is ordered for 7. Answer: (B) Keep the irrigating container pneumonectomy is done, there is a need
the child. The bottle of Lanoxin contains .05 mg less than 18 inches above the stoma.” to promote expansion of this remaining
of Lanoxin in 1 ml of solution. What amount Rationale: This height permits the solution Left lung by positioning the client on the
should the nurse administer to the child? to flow slowly with little force so that opposite unoperated side.
a. 1.2 ml excessive peristalsis is not immediately 15. Answer: (A) Food and fluids will be
b. 2.4 ml precipitated. withheld for at least 2 hours.
c. 3.5 ml 8. Answer: (A) Administer Kayexalate Rationale: Prior to bronchoscopy, the
d. 4.2 ml Rationale: Kayexalate,a potassium doctors sprays the back of the throat with
exchange resin, permits sodium to be anesthetic to minimize the gag reflex and
100. Nurse Alexandra teaches a client about elastic exchanged for potassium in the intestine, thus facilitate the insertion of the
stockings. Which of the following statements, reducing the serum potassium level. bronchoscope. Giving the client food and
if made by the client, indicates to the nurse 9. Answer:(B) 28 gtt/min drink after the procedure without
that the teaching was successful? Rationale: This is the correct flow rate; checking on the return of the gag reflex
a. “I will wear the stockings until the multiply the amount to be infused (2000 can cause the client to aspirate. The gag
physician tells me to remove them.” ml) by the drop factor (10) and divide the reflex usually returns after two hours.
b. “I should wear the stockings even when I result by the amount of time in minutes 16. Answer: (C) hyperkalemia.
am sleep.” (12 hours x 60 minutes)
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Rationale: Hyperkalemia is a common increases serum levels of potassium, left side with knees bent. Placing the capillaries become occluded, reducing
complication of acute renal failure. It's magnesium, and phosphorous, and client on the right side with legs straight, circulation and oxygenation of the tissues
life-threatening if immediate action isn't decreases serum levels of calcium. A uric prone with the torso elevated, or bent and resulting in cell death and ulcer
taken to reverse it. The administration of acid analysis of 3.5 mg/dl falls within the over with hands touching the floor formation. During passive ROM exercises,
glucose and regular insulin, with sodium normal range of 2.7 to 7.7 mg/dl; PSP wouldn't allow proper visualization of the the nurse moves each joint through its
bicarbonate if necessary, can temporarily excretion of 75% also falls with the normal large intestine. range of movement, which improves joint
prevent cardiac arrest by moving range of 60% to 75%. 25. Answer: (A) Blood supply to the stoma has mobility and circulation to the affected
potassium into the cells and temporarily 20. Answer: (D) Alteration in the size, shape, been interrupted area but doesn't prevent pressure ulcers.
reducing serum potassium levels. and organization of differentiated cells Rationale: An ileostomy stoma forms as Adequate hydration is necessary to
Hypernatremia, hypokalemia, and Rationale: Dysplasia refers to an alteration the ileum is brought through the maintain healthy skin and ensure tissue
hypercalcemia don't usually occur with in the size, shape, and organization of abdominal wall to the surface skin, repair. A footboard prevents plantar
acute renal failure and aren't treated with differentiated cells. The presence of creating an artificial opening for waste flexion and footdrop by maintaining the
glucose, insulin, or sodium bicarbonate. completely undifferentiated tumor cells elimination. The stoma should appear foot in a dorsiflexed position.
17. Answer: (A) This condition puts her at a that don't resemble cells of the tissues of cherry red, indicating adequate arterial 29. Answer: (C) In long, even, outward, and
higher risk for cervical cancer; therefore, their origin is called anaplasia. An increase perfusion. A dusky stoma suggests downward strokes in the direction of hair
she should have a Papanicolaou (Pap) in the number of normal cells in a normal decreased perfusion, which may result growth
smear annually. arrangement in a tissue or an organ is from interruption of the stoma's blood Rationale: When applying a topical agent,
Rationale: Women with condylomata called hyperplasia. Replacement of one supply and may lead to tissue damage or the nurse should begin at the midline and
acuminata are at risk for cancer of the type of fully differentiated cell by another necrosis. A dusky stoma isn't a normal use long, even, outward, and downward
cervix and vulva. Yearly Pap smears are in tissues where the second type normally finding. Adjusting the ostomy bag strokes in the direction of hair growth.
very important for early detection. isn't found is called metaplasia. wouldn't affect stoma color, which This application pattern reduces the risk
Because condylomata acuminata is a 21. Answer: (D) Kaposi's sarcoma depends on blood supply to the area. An of follicle irritation and skin inflammation.
virus, there is no permanent cure. Rationale: Kaposi's sarcoma is the most intestinal obstruction also wouldn't 30. Answer: (A) Beta -adrenergic blockers
Because condylomata acuminata can common cancer associated with AIDS. change stoma color. Rationale: Beta-adrenergic blockers work
occur on the vulva, a condom won't Squamous cell carcinoma, multiple 26. Answer: (A) Applying knee splints by blocking beta receptors in the
protect sexual partners. HPV can be myeloma, and leukemia may occur in Rationale: Applying knee splints prevents myocardium, reducing the response to
transmitted to other parts of the body, anyone and aren't associated specifically leg contractures by holding the joints in a catecholamines and sympathetic nerve
such as the mouth, oropharynx, and with AIDS. position of function. Elevating the foot of stimulation. They protect the
larynx. 22. Answer: (C) To prevent cerebrospinal fluid the bed can't prevent contractures myocardium, helping to reduce the risk of
18. Answer: (A) The left kidney usually is (CSF) leakage because this action doesn't hold the joints another infraction by decreasing
slightly higher than the right one. Rationale: The client receiving a in a position of function. Hyperextending a myocardial oxygen demand. Calcium
Rationale: The left kidney usually is subarachnoid block requires special body part for an extended time is channel blockers reduce the workload of
slightly higher than the right one. An positioning to prevent CSF leakage and inappropriate because it can cause the heart by decreasing the heart rate.
adrenal gland lies atop each kidney. The headache and to ensure proper anesthetic contractures. Performing shoulder range- Narcotics reduce myocardial oxygen
average kidney measures approximately distribution. Proper positioning doesn't of-motion exercises can prevent demand, promote vasodilation, and
11 cm (4-3/8") long, 5 to 5.8 cm (2" to help prevent confusion, seizures, or contractures in the shoulders, but not in decrease anxiety. Nitrates reduce
2¼") wide, and 2.5 cm (1") thick. The cardiac arrhythmias. the legs. myocardial oxygen consumption bt
kidneys are located retroperitoneally, in 23. Answer: (A) Auscultate bowel sounds. 27. Answer: (B) Urine output of 20 ml/hour. decreasing left ventricular end diastolic
the posterior aspect of the abdomen, on Rationale: If abdominal distention is Rationale: A urine output of less than 40 pressure (preload) and systemic vascular
either side of the vertebral column. They accompanied by nausea, the nurse must ml/hour in a client with burns indicates a resistance (afterload).
lie between the 12th thoracic and 3rd first auscultate bowel sounds. If bowel fluid volume deficit. This client's PaO2 31. Answer: (C) Raised 30 degrees
lumbar vertebrae. sounds are absent, the nurse should value falls within the normal range (80 to Rationale: Jugular venous pressure is
19. Answer: (C) Blood urea nitrogen (BUN) suspect gastric or small intestine dilation 100 mm Hg). White pulmonary secretions measured with a centimeter ruler to
100 mg/dl and serum creatinine 6.5mg/dl. and these findings must be reported to also are normal. The client's rectal obtain the vertical distance between the
Rationale: The normal BUN level ranges 8 the physician. Palpation should be temperature isn't significantly elevated sternal angle and the point of highest
to 23 mg/dl; the normal serum creatinine avoided postoperatively with abdominal and probably results from the fluid pulsation with the head of the bed
level ranges from 0.7 to 1.5 mg/dl. The distention. If peristalsis is absent, volume deficit. inclined between 15 to 30 degrees.
test results in option C are abnormally changing positions and inserting a rectal 28. Answer: (A) Turn him frequently. Increased pressure can’t be seen when
elevated, reflecting CRF and the kidneys' tube won't relieve the client's discomfort. Rationale: The most important the client is supine or when the head of
decreased ability to remove nonprotein 24. Answer: (B) Lying on the left side with intervention to prevent pressure ulcers is the bed is raised 10 degrees because the
nitrogen waste from the blood. CRF knees bent frequent position changes, which relieve point that marks the pressure level is
causes decreased pH and increased Rationale: For a colonoscopy, the nurse pressure on the skin and underlying above the jaw (therefore, not visible). In
hydrogen ions — not vice versa. CRF also initially should position the client on the tissues. If pressure isn't relieved,
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high Fowler’s position, the veins would be ventricular fibrillation and atrial flutter – species. A syngeneic transplant is between options, which reflect parts of the nervous
barely discernible above the clavicle. not symptomatic bradycardia. identical twins, allogeneic transplant is system, aren’t usually affected by MM.
32. Answer: (D) Inotropic agents 36. Answer: (C) 95 mm Hg between two humans, and autologous is a 46. Answer: (C) 10 years
Rationale: Inotropic agents are Rationale: Use the following formula to transplant from the same individual. Rationale: Epidermiologic studies show
administered to increase the force of the calculate MAP 41. Answer: (B) the average time from initial contact with
heart’s contractions, thereby increasing MAP = systolic + 2 (diastolic) Rationale: Tissue thromboplastin is HIV to the development of AIDS is 10
ventricular contractility and ultimately 3 released when damaged tissue comes in years.
increasing cardiac output. Beta-adrenergic MAP=126 mm Hg + 2 (80 mm Hg) contact with clotting factors. Calcium is 47. Answer: (A) Low platelet count
blockers and calcium channel blockers 3 released to assist the conversion of Rationale: In DIC, platelets and clotting
decrease the heart rate and ultimately MAP=286 mm HG factors X to Xa. Conversion of factors XII to factors are consumed, resulting in
decreased the workload of the heart. 3 XIIa and VIII to IIIa are part of the intrinsic microthrombi and excessive bleeding. As
Diuretics are administered to decrease the MAP=95 mm Hg pathway. clots form, fibrinogen levels decrease and
overall vascular volume, also decreasing 37. Answer: (C) Electrocardiogram, complete 42. Answer: (C) Essential thrombocytopenia the prothrombin time increases. Fibrin
the workload of the heart. blood count, testing for occult blood, Rationale: Essential thrombocytopenia is degeneration products increase as
33. Answer: (B) Less than 30% of calories from comprehensive serum metabolic panel. linked to immunologic disorders, such as fibrinolysis takes places.
fat Rationale: An electrocardiogram evaluates SLE and human immunodeficiency virus. 48. Answer: (D) Hodgkin’s disease
Rationale: A client with low serum HDL the complaints of chest pain, laboratory The disorder known as von Willebrand’s Rationale: Hodgkin’s disease typically
and high serum LDL levels should get less tests determines anemia, and the stool disease is a type of hemophilia and isn’t causes fever night sweats, weight loss,
than 30% of daily calories from fat. The test for occult blood determines blood in linked to SLE. Moderate to severe anemia and lymph mode enlargement. Influenza
other modifications are appropriate for the stool. Cardiac monitoring, oxygen, and is associated with SLE, not polycythemia. doesn’t last for months. Clients with sickle
this client. creatine kinase and lactate Dressler’s syndrome is pericarditis that cell anemia manifest signs and symptoms
34. Answer: (C) The emergency department dehydrogenase levels are appropriate for occurs after a myocardial infarction and of chronic anemia with pallor of the
nurse calls up the latest electrocardiogram a cardiac primary problem. A basic isn’t linked to SLE. mucous membrane, fatigue, and
results to check the client’s progress metabolic panel and alkaline phosphatase 43. Answer: (B) Night sweat decreased tolerance for exercise; they
Rationale: The emergency department and aspartate aminotransferase levels Rationale: In stage 1, symptoms include a don’t show fever, night sweats, weight
nurse is no longer directly involved with assess liver function. Prothrombin time, single enlarged lymph node (usually), loss or lymph node enlargement.
the client’s care and thus has no legal partial thromboplastin time, fibrinogen unexplained fever, night sweats, malaise, Leukemia doesn’t cause lymph node
right to information about his present and fibrin split products are measured to and generalized pruritis. Although enlargement.
condition. Anyone directly involved in his verify bleeding dyscrasias; an splenomegaly may be present in some 49. Answer: (C) A Rh-negative
care (such as the telemetry nurse and the electroencephalogram evaluates brain clients, night sweats are generally more Rationale: Human blood can sometimes
on-call physician) has the right to electrical activity. prevalent. Pericarditis isn’t associated contain an inherited D antigen. Persons
information about his condition. Because 38. Answer: (D) Heparin-associated with Hodgkin’s disease, nor is with the D antigen have Rh-positive blood
the client requested that the nurse update thrombosis and thrombocytopenia (HATT) hypothermia. Moreover, splenomegaly type; those lacking the antigen have Rh-
his wife on his condition, doing so doesn’t Rationale: HATT may occur after CABG and pericarditis aren’t symptoms. negative blood. It’s important that a
breach confidentiality. surgery due to heparin use during surgery. Persistent hypothermia is associated with person with Rh- negative blood receives
35. Answer: (B) Check endotracheal tube Although DIC and ITP cause platelet Hodgkin’s but isn’t an early sign of the Rh-negative blood. If Rh-positive blood is
placement. aggregation and bleeding, neither is disease. administered to an Rh-negative person,
Rationale: ET tube placement should be common in a client after revascularization 44. Answer: (D) Breath sounds the recipient develops anti-Rh agglutinins,
confirmed as soon as the client arrives in surgery. Pancytopenia is a reduction in all Rationale: Pneumonia, both viral and and sub sequent transfusions with Rh-
the emergency department. Once the blood cells. fungal, is a common cause of death in positive blood may cause serious
airways is secured, oxygenation and 39. Answer: (B) Corticosteroids clients with neutropenia, so frequent reactions with clumping and hemolysis of
ventilation should be confirmed using an Rationale: Corticosteroid therapy can assessment of respiratory rate and breath red blood cells.
end-tidal carbon dioxide monitor and decrease antibody production and sounds is required. Although assessing 50. Answer: (B) “I will call my doctor if Stacy
pulse oximetry. Next, the nurse should phagocytosis of the antibody-coated blood pressure, bowel sounds, and heart has persistent vomiting and diarrhea”.
make sure L.V. access is established. If the platelets, retaining more functioning sounds is important, it won’t help detect Rationale: Persistent (more than 24 hours)
client experiences symptomatic platelets. Methotrexate can cause pneumonia. vomiting, anorexia, and diarrhea are signs
bradycardia, atropine is administered as thrombocytopenia. Vitamin K is used to 45. Answer: (B) Muscle spasm of toxicity and the patient should stop the
ordered 0.5 to 1 mg every 3 to 5 minutes treat an excessive anticoagulate state Rationale: Back pain or paresthesia in the medication and notify the health care
to a total of 3 mg. Then the nurse should from warfarin overload, and ASA lower extremities may indicate impending provider. The other manifestations are
try to find the cause of the client’s arrest decreases platelet aggregation. spinal cord compression from a spinal expected side effects of chemotherapy.
by obtaining an ABG sample. Amiodarone 40. Answer: (D) Xenogeneic tumor. This should be recognized and 51. Answer: (D) “This is only temporary; Stacy
is indicated for ventricular tachycardia, Rationale: An xenogeneic transplant is treated promptly as progression of the will re-grow new hair in 3-6 months, but
between is between human and another tumor may result in paraplegia. The other may be different in texture”.
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Rationale: This is the appropriate chronic obstructive bronchitis are bloated 62. Answer: (C) “I’ll lower the dosage as diagnosis test. Nitroglycerin is an oral
response. The nurse should help the and cyanotic in appearance. ordered so the drug causes only 2 to 4 sublingual medication. Cardiac
mother how to cope with her own feelings 56. Answer: D 80 mm Hg stools a day”. catheterization is a diagnostic tool – not a
regarding the child’s disease so as not to Rationale: A client about to go into Rationale: Lactulose is given to a patients treatment.
affect the child negatively. When the hair respiratory arrest will have inefficient with hepatic encephalopathy to reduce 66. Answer: (B) Cardiogenic shock
grows back, it is still of the same color and ventilation and will be retaining carbon absorption of ammonia in the intestines Rationale: Cardiogenic shock is shock
texture. dioxide. The value expected would be by binding with ammonia and promoting related to ineffective pumping of the
52. Answer: (B) Apply viscous Lidocaine to around 80 mm Hg. All other values are more frequent bowel movements. If the heart. Anaphylactic shock results from an
oral ulcers as needed. lower than expected. patient experience diarrhea, it indicates allergic reaction. Distributive shock results
Rationale: Stomatitis can cause pain and 57. Answer: (C) Respiratory acidosis over dosage and the nurse must reduce from changes in the intravascular volume
this can be relieved by applying topical Rationale: Because Paco2 is high at 80 mm the amount of medication given to the distribution and is usually associated with
anesthetics such as lidocaine before Hg and the metabolic measure, HCO3- is patient. The stool will be mashy or soft. increased cardiac output. MI isn’t a shock
mouth care. When the patient is already normal, the client has respiratory acidosis. Lactulose is also very sweet and may state, though a severe MI can lead to
comfortable, the nurse can proceed with The pH is less than 7.35, academic, which cause cramping and bloating. shock.
providing the patient with oral rinses of eliminates metabolic and respiratory 63. Answer: (B) Severe lower back pain, 67. Answer: (C) Kidneys’ excretion of sodium
saline solution mixed with equal part of alkalosis as possibilities. If the HCO3- was decreased blood pressure, decreased RBC and water
water or hydrogen peroxide mixed water below 22 mEq/L the client would have count, increased WBC count. Rationale: The kidneys respond to rise in
in 1:3 concentrations to promote oral metabolic acidosis. Rationale: Severe lower back pain blood pressure by excreting sodium and
hygiene. Every 2-4 hours. 58. Answer: (C) Respiratory failure indicates an aneurysm rupture, secondary excess water. This response ultimately
53. Answer: (C) Immediately discontinue the Rationale: The client was reacting to the to pressure being applied within the affects sysmolic blood pressure by
infusion drug with respiratory signs of impending abdominal cavity. When ruptured occurs, regulating blood volume. Sodium or water
Rationale: Edema or swelling at the IV site anaphylaxis, which could lead to the pain is constant because it can’t be retention would only further increase
is a sign that the needle has been eventually respiratory failure. Although alleviated until the aneurysm is repaired. blood pressure. Sodium and water travel
dislodged and the IV solution is leaking the signs are also related to an asthma Blood pressure decreases due to the loss together across the membrane in the
into the tissues causing the edema. The attack or a pulmonary embolism, consider of blood. After the aneurysm ruptures, the kidneys; one can’t travel without the
patient feels pain as the nerves are the new drug first. Rheumatoid arthritis vasculature is interrupted and blood other.
irritated by pressure and the IV solution. doesn’t manifest these signs. volume is lost, so blood pressure wouldn’t 68. Answer: (D) It inhibits reabsorption of
The first action of the nurse would be to 59. Answer: (D) Elevated serum increase. For the same reason, the RBC sodium and water in the loop of Henle.
discontinue the infusion right away to aminotransferase count is decreased – not increased. The Rationale: Furosemide is a loop diuretic
prevent further edema and other Rationale: Hepatic cell death causes WBC count increases as cell migrate to the that inhibits sodium and water
complication. release of liver enzymes alanine site of injury. reabsorption in the loop Henle, thereby
54. Answer: (C) Chronic obstructive bronchitis aminotransferase (ALT), aspartate 64. Answer: (D) Apply gloves and assess the causing a decrease in blood pressure.
Rationale: Clients with chronic obstructive aminotransferase (AST) and lactate groin site Vasodilators cause dilation of peripheral
bronchitis appear bloated; they have large dehydrogenase (LDH) into the circulation. Rationale: Observing standard precautions blood vessels, directly relaxing vascular
barrel chest and peripheral edema, Liver cirrhosis is a chronic and irreversible is the first priority when dealing with any smooth muscle and decreasing blood
cyanotic nail beds, and at times, disease of the liver characterized by blood fluid. Assessment of the groin site is pressure. Adrenergic blockers decrease
circumoral cyanosis. Clients with ARDS are generalized inflammation and fibrosis of the second priority. This establishes where sympathetic cardioacceleration and
acutely short of breath and frequently the liver tissues. the blood is coming from and determines decrease blood pressure. Angiotensin-
need intubation for mechanical ventilation 60. Answer: (A) Impaired clotting mechanism how much blood has been lost. The goal in converting enzyme inhibitors decrease
and large amount of oxygen. Clients with Rationale: Cirrhosis of the liver results in this situation is to stop the bleeding. The blood pressure due to their action on
asthma don’t exhibit characteristics of decreased Vitamin K absorption and nurse would call for help if it were angiotensin.
chronic disease, and clients with formation of clotting factors resulting in warranted after the assessment of the 69. Answer: (C) Pancytopenia, elevated
emphysema appear pink and cachectic. impaired clotting mechanism. situation. After determining the extent of antinuclear antibody (ANA) titer
55. Answer: (D) Emphysema 61. Answer: (B) Altered level of consciousness the bleeding, vital signs assessment is Rationale: Laboratory findings for clients
Rationale: Because of the large amount of Rationale: Changes in behavior and level important. The nurse should never move with SLE usually show pancytopenia,
energy it takes to breathe, clients with of consciousness are the first sins of the client, in case a clot has formed. elevated ANA titer, and decreased serum
emphysema are usually cachectic. They’re hepatic encephalopathy. Hepatic Moving can disturb the clot and cause complement levels. Clients may have
pink and usually breathe through pursed encephalopathy is caused by liver failure rebleeding. elevated BUN and creatinine levels from
lips, hence the term “puffer.” Clients with and develops when the liver is unable to 65. Answer: (D) Percutaneous transluminal nephritis, but the increase does not
ARDS are usually acutely short of breath. convert protein metabolic product coronary angioplasty (PTCA) indicate SLE.
Clients with asthma don’t have any ammonia to urea. This results in Rationale: PTCA can alleviate the blockage 70. Answer: (C) Narcotics are avoided after a
particular characteristics, and clients with accumulation of ammonia and other toxic and restore blood flow and oxygenation. head injury because they may hide a
in the blood that damages the cells. An echocardiogram is a noninvasive worsening condition.
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Rationale: Narcotics may mask changes in 75. Answer: (C) Myxedema coma antidiabetic agents usually doesn't need dangerously imbalanced. Temperature
the level of consciousness that indicate Rationale: Myxedema coma, severe to monitor blood glucose levels. A high- regulation may be affected by excess
increased ICP and shouldn’t hypothyroidism, is a life-threatening carbohydrate diet would exacerbate the cortisol and isn't an accurate indicator of
acetaminophen is strong enough ignores condition that may develop if thyroid client's condition, particularly if fluid infection.
the mother’s question and therefore isn’t replacement medication isn't taken. intake is low. 83. Answer: (C) onset to be at 2:30 p.m. and
appropriate. Aspirin is contraindicated in Exophthalmos, protrusion of the eyeballs, 79. Answer: (D) Hyperparathyroidism its peak to be at 4 p.m.
conditions that may have bleeding, such is seen with hyperthyroidism. Thyroid Rationale: Hyperparathyroidism is most Rationale: Regular insulin, which is a
as trauma, and for children or young storm is life-threatening but is caused by common in older women and is short-acting insulin, has an onset of 15 to
adults with viral illnesses due to the severe hyperthyroidism. Tibial myxedema, characterized by bone pain and weakness 30 minutes and a peak of 2 to 4 hours.
danger of Reye’s syndrome. Stronger peripheral mucinous edema involving the from excess parathyroid hormone (PTH). Because the nurse gave the insulin at 2
medications may not necessarily lead to lower leg, is associated with Clients also exhibit hypercaliuria-causing p.m., the expected onset would be from
vomiting but will sedate the client, hypothyroidism but isn't life-threatening. polyuria. While clients with diabetes 2:15 p.m. to 2:30 p.m. and the peak from
thereby masking changes in his level of 76. Answer: (B) An irregular apical pulse mellitus and diabetes insipidus also have 4 p.m. to 6 p.m.
consciousness. Rationale: Because Cushing's syndrome polyuria, they don't have bone pain and 84. Answer: (A) No increase in the thyroid-
71. Answer: (A) Appropriate; lowering carbon causes aldosterone overproduction, which increased sleeping. Hypoparathyroidism is stimulating hormone (TSH) level after 30
dioxide (CO2) reduces intracranial increases urinary potassium loss, the characterized by urinary frequency rather minutes during the TSH stimulation test
pressure (ICP) disorder may lead to hypokalemia. than polyuria. Rationale: In the TSH test, failure of the
Rationale: A normal Paco2 value is 35 to Therefore, the nurse should immediately 80. Answer: (C) "I'll take two-thirds of the TSH level to rise after 30 minutes confirms
45 mm Hg CO2 has vasodilating report signs and symptoms of dose when I wake up and one-third in the hyperthyroidism. A decreased TSH level
properties; therefore, lowering Paco2 hypokalemia, such as an irregular apical late afternoon." indicates a pituitary deficiency of this
through hyperventilation will lower ICP pulse, to the physician. Edema is an Rationale: Hydrocortisone, a hormone. Below-normal levels of T3 and
caused by dilated cerebral vessels. expected finding because aldosterone glucocorticoid, should be administered T4, as detected by radioimmunoassay,
Oxygenation is evaluated through Pao2 overproduction causes sodium and fluid according to a schedule that closely signal hypothyroidism. A below-normal T4
and oxygen saturation. Alveolar retention. Dry mucous membranes and reflects the bodies own secretion of this level also occurs in malnutrition and liver
hypoventilation would be reflected in an frequent urination signal dehydration, hormone; therefore, two-thirds of the disease and may result from
increased Paco2. which isn't associated with Cushing's dose of hydrocortisone should be taken in administration of phenytoin and certain
72. Answer: (B) A 33-year-old client with a syndrome. the morning and one-third in the late other drugs.
recent diagnosis of Guillain-Barre 77. Answer: (D) Below-normal urine afternoon. This dosage schedule reduces 85. Answer: (B) "Rotate injection sites within
syndrome osmolality level, above-normal serum adverse effects. the same anatomic region, not among
Rationale: Guillain-Barre syndrome is osmolality level 81. Answer: (C) High corticotropin and high different regions."
characterized by ascending paralysis and Rationale: In diabetes insipidus, excessive cortisol levels Rationale: The nurse should instruct the
potential respiratory failure. The order of polyuria causes dilute urine, resulting in a Rationale: A corticotropin-secreting client to rotate injection sites within the
client assessment should follow client below-normal urine osmolality level. At pituitary tumor would cause high same anatomic region. Rotating sites
priorities, with disorder of airways, the same time, polyuria depletes the body corticotropin and high cortisol levels. A among different regions may cause
breathing, and then circulation. There’s no of water, causing dehydration that leads high corticotropin level with a low cortisol excessive day-to-day variations in the
information to suggest the postmyocardial to an above-normal serum osmolality level and a low corticotropin level with a blood glucose level; also, insulin
infarction client has an arrhythmia or level. For the same reasons, diabetes low cortisol level would be associated absorption differs from one region to the
other complication. There’s no evidence insipidus doesn't cause above-normal with hypocortisolism. Low corticotropin next. Insulin should be injected only into
to suggest hemorrhage or perforation for urine osmolality or below-normal serum and high cortisol levels would be seen if healthy tissue lacking large blood vessels,
the remaining clients as a priority of care. osmolality levels. there was a primary defect in the adrenal nerves, or scar tissue or other deviations.
73. Answer: (C) Decreases inflammation 78. Answer: (A) "I can avoid getting sick by not glands. Injecting insulin into areas of hypertrophy
Rationale: Then action of colchicines is to becoming dehydrated and by paying 82. Answer: (D) Performing capillary glucose may delay absorption. The client shouldn't
decrease inflammation by reducing the attention to my need to urinate, drink, or testing every 4 hours inject insulin into areas of lipodystrophy
migration of leukocytes to synovial fluid. eat more than usual." Rationale: The nurse should perform (such as hypertrophy or atrophy); to
Colchicine doesn’t replace estrogen, Rationale: Inadequate fluid intake during capillary glucose testing every 4 hours prevent lipodystrophy, the client should
decrease infection, or decrease bone hyperglycemic episodes often leads to because excess cortisol may cause insulin rotate injection sites systematically.
demineralization. HHNS. By recognizing the signs of resistance, placing the client at risk for Exercise speeds drug absorption, so the
74. Answer: (C) Osteoarthritis is the most hyperglycemia (polyuria, polydipsia, and hyperglycemia. Urine ketone testing isn't client shouldn't inject insulin into sites
common form of arthritis polyphagia) and increasing fluid intake, indicated because the client does secrete above muscles that will be exercised
Rationale: Osteoarthritis is the most the client may prevent HHNS. Drinking a insulin and, therefore, isn't at risk for heavily.
common form of arthritis and can be glass of nondiet soda would be ketosis. Urine specific gravity isn't 86. Answer: (D) Below-normal serum
extremely debilitating. It can afflict people appropriate for hypoglycemia. A client indicated because although fluid balance potassium level
of any age, although most are elderly. whose diabetes is controlled with oral can be compromised, it usually isn't
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Rationale: A client with HHNS has an He could develop atelectasis but it leak can occur as air is pulled from the
overall body deficit of potassium resulting typically doesn’t produce progressive pleural space. Bubbling doesn’t normally
from diuresis, which occurs secondary to hypoxia. occur with either adequate or inadequate
the hyperosmolar, hyperglycemic state 92. Answer: (D) Spontaneous pneumothorax suction or any preexisting bubbling in the
caused by the relative insulin deficiency. Rationale: A spontaneous pneumothorax water seal chamber.
An elevated serum acetone level and occurs when the client’s lung collapses, 98. Answer: (B) 21
serum ketone bodies are characteristic of causing an acute decreased in the amount Rationale: 3000 x 10 divided by 24 x 60.
diabetic ketoacidosis. Metabolic acidosis, of functional lung used in oxygenation. 99. Answer: (B) 2.4 ml
not serum alkalosis, may occur in HHNS. The sudden collapse was the cause of his Rationale: .05 mg/ 1 ml = .12mg/ x ml,
87. Answer: (D) Maintaining room chest pain and shortness of breath. An .05x = .12, x = 2.4 ml.
temperature in the low-normal range asthma attack would show wheezing 100. Answer: (D) “I should put on the stockings
Rationale: Graves' disease causes signs breath sounds, and bronchitis would have before getting out of bed in the morning.
and symptoms of hypermetabolism, such rhonchi. Pneumonia would have bronchial Rationale: Promote venous return by
as heat intolerance, diaphoresis, excessive breath sounds over the area of applying external pressure on veins.
thirst and appetite, and weight loss. To consolidation.
reduce heat intolerance and diaphoresis, 93. Answer: (C) Pneumothorax
the nurse should keep the client's room Rationale: From the trauma the client
temperature in the low-normal range. To experienced, it’s unlikely he has
replace fluids lost via diaphoresis, the bronchitis, pneumonia, or TB; rhonchi
nurse should encourage, not restrict, with bronchitis, bronchial breath sounds
intake of oral fluids. Placing extra blankets with TB would be heard.
on the bed of a client with heat 94. Answer: (C) Serous fluids fills the space
intolerance would cause discomfort. To and consolidates the region
provide needed energy and calories, the Rationale: Serous fluid fills the space and
nurse should encourage the client to eat eventually consolidates, preventing
high-carbohydrate foods. extensive mediastinal shift of the heart
88. Answer: (A) Fracture of the distal radius and remaining lung. Air can’t be left in the
Rationale: Colles' fracture is a fracture of space. There’s no gel that can be placed in
the distal radius, such as from a fall on an the pleural space. The tissue from the
outstretched hand. It's most common in other lung can’t cross the mediastinum,
women. Colles' fracture doesn't refer to a although a temporary mediastinal shift
fracture of the olecranon, humerus, or exits until the space is filled.
carpal scaphoid. 95. Answer: (A) Alveolar damage in the
89. Answer: (B) Calcium and phosphorous infracted area
Rationale: In osteoporosis, bones lose Rationale: The infracted area produces
calcium and phosphate salts, becoming alveolar damage that can lead to the
porous, brittle, and abnormally vulnerable production of bloody sputum, sometimes
to fracture. Sodium and potassium aren't in massive amounts. Clot formation
involved in the development of usually occurs in the legs. There’s a loss of
steoporosis. lung parenchyma and subsequent scar
90. Answer: (A) Adult respiratory distress tissue formation.
syndrome (ARDS) 96. Answer: (D) Respiratory alkalosis
Rationale: Severe hypoxia after smoke Rationale: A client with massive
inhalation is typically related to ARDS. The pulmonary embolism will have a large
other conditions listed aren’t typically region and blow off large amount of
associated with smoke inhalation and carbon dioxide, which crosses the
severe hypoxia. unaffected alveolar-capillary membrane
91. Answer: (D) Fat embolism more readily than does oxygen and results
Rationale: Long bone fractures are in respiratory alkalosis.
correlated with fat emboli, which cause 97. Answer: (A) Air leak
shortness of breath and hypoxia. It’s Rationale: Bubbling in the water seal
unlikely the client has developed asthma chamber of a chest drainage system stems
or bronchitis without a previous history. from an air leak. In pneumothorax an air
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TEST V - Care of Clients with Physiologic and d. Suggest that the father and son work d. Increase calories, carbohydrates, and deal with this conflict if you want to walk
Psychosocial Alterations things out. protein. again."
b. "It must be awful not to be able to move
1. Mr. Marquez reports of losing his job, not being 5. What is Nurse John likely to note in a male client 10. What parental behavior toward a child during an your legs. You may feel better if you
able to sleep at night, and feeling upset with his being admitted for alcohol withdrawal? admission procedure should cause Nurse Ron to realize the problem is psychological, not
wife. Nurse John responds to the client, “You a. Perceptual disorders. suspect child abuse? physical."
may want to talk about your employment b. Impending coma. a. Flat affect c. "Your problem is real but there is no
situation in group today.” The Nurse is using c. Recent alcohol intake. b. Expressing guilt physical basis for it. We'll work on what
which therapeutic technique? d. Depression with mutism. c. Acting overly solicitous toward the child. is going on in your life to find out why
a. Observations d. Ignoring the child. it's happened."
b. Restating 6. Aira has taken amitriptyline HCL (Elavil) for 3 d. "It isn't uncommon for someone with
c. Exploring days, but now complains that it “doesn’t help” 11. Nurse Lynnette notices that a female client with your personality to develop a conversion
d. Focusing and refuses to take it. What should the nurse say obsessive-compulsive disorder washes her hands disorder during times of stress."
or do? for long periods each day. How should the nurse
2. Tony refuses his evening dose of Haloperidol a. Withhold the drug. respond to this compulsive behavior? 14. Nurse Krina knows that the following drugs have
(Haldol), then becomes extremely agitated in the b. Record the client’s response. a. By designating times during which the been known to be effective in treating
dayroom while other clients are watching c. Encourage the client to tell the doctor. client can focus on the behavior. obsessive-compulsive disorder (OCD):
television. He begins cursing and throwing d. Suggest that it takes a while before b. By urging the client to reduce the a. benztropine (Cogentin) and
furniture. Nurse Oliver first action is to: seeing the results. frequency of the behavior as rapidly as diphenhydramine (Benadryl).
a. Check the client’s medical record for an possible. b. chlordiazepoxide (Librium) and
order for an as-needed I.M. dose of 7. Dervid, an adolescent has a history of truancy c. By calling attention to or attempting to diazepam (Valium)
medication for agitation. from school, running away from home and prevent the behavior. c. fluvoxamine (Luvox) and clomipramine
b. Place the client in full leather restraints. “barrowing” other people’s things without their d. By discouraging the client from (Anafranil)
c. Call the attending physician and report permission. The adolescent denies stealing, verbalizing anxieties. d. divalproex (Depakote) and lithium
the behavior. rationalizing instead that as long as no one was (Lithobid)
d. Remove all other clients from the using the items, it was all right to borrow them. 12. After seeking help at an outpatient mental
dayroom. It is important for the nurse to understand the health clinic, Ruby who was raped while walking 15. Alfred was newly diagnosed with anxiety
psychodynamically, this behavior may be largely her dog is diagnosed with posttraumatic stress disorder. The physician prescribed buspirone
3. Tina who is manic, but not yet on medication, attributed to a developmental defect related to disorder (PTSD). Three months later, Ruby (BuSpar). The nurse is aware that the teaching
comes to the drug treatment center. The nurse the: returns to the clinic, complaining of fear, loss of instructions for newly prescribed buspirone
would not let this client join the group session a. Id control, and helpless feelings. Which nursing should include which of the following?
because: b. Ego intervention is most appropriate for Ruby? a. A warning about the drugs delayed
a. The client is disruptive. c. Superego a. Recommending a high-protein, low-fat therapeutic effect, which is from 14 to
b. The client is harmful to self. d. Oedipal complex diet. 30 days.
c. The client is harmful to others. b. Giving sleep medication, as prescribed, b. A warning about the incidence of
d. The client needs to be on medication 8. In preparing a female client for electroconvulsive to restore a normal sleep- wake cycle. neuroleptic malignant syndrome (NMS).
first. therapy (ECT), Nurse Michelle knows that c. Allowing the client time to heal. c. A reminder of the need to schedule
succinylcoline (Anectine) will be administered d. Exploring the meaning of the traumatic blood work in 1 week to check blood
4. Dervid, an adolescent boy was admitted for for which therapeutic effect? event with the client. levels of the drug.
substance abuse and hallucinations. The client’s a. Short-acting anesthesia d. A warning that immediate sedation can
mother asks Nurse Armando to talk with his b. Decreased oral and respiratory 13. Meryl, age 19, is highly dependent on her occur with a resultant drop in pulse.
husband when he arrives at the hospital. The secretions. parents and fears leaving home to go away to
mother says that she is afraid of what the father c. Skeletal muscle paralysis. college. Shortly before the semester starts, she 16. Richard with agoraphobia has been symptom-
might say to the boy. The most appropriate d. Analgesia. complains that her legs are paralyzed and is free for 4 months. Classic signs and symptoms of
nursing intervention would be to: rushed to the emergency department. When phobias include:
a. Inform the mother that she and the 9. Nurse Gina is aware that the dietary implications physical examination rules out a physical cause a. Insomnia and an inability to concentrate.
father can work through this problem for a client in manic phase of bipolar disorder is: for her paralysis, the physician admits her to the b. Severe anxiety and fear.
themselves. a. Serve the client a bowl of soup, buttered psychiatric unit where she is diagnosed with c. Depression and weight loss.
b. Refer the mother to the hospital social French bread, and apple slices. conversion disorder. Meryl asks the nurse, "Why d. Withdrawal and failure to distinguish
worker. b. Increase calories, decrease fat, and has this happened to me?" What is the nurse's reality from fantasy.
c. Agree to talk with the mother and the decrease protein. best response?
father together. c. Give the client pieces of cut-up steak, a. "You've developed this paralysis so you 17. Which medications have been found to help
carrots, and an apple. can stay with your parents. You must reduce or eliminate panic attacks?
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a. Antidepressants d. A low tolerance for frustration d. Listening attentively with a neutral 32. The nurse is aware that the side effect of
b. Anticholinergics attitude and avoiding power struggles. electroconvulsive therapy that a client may
c. Antipsychotics 22. Nurse Amy is providing care for a male client experience:
d. Mood stabilizers undergoing opiate withdrawal. Opiate 27. Ramon is admitted for detoxification after a a. Loss of appetite
withdrawal causes severe physical discomfort cocaine overdose. The client tells the nurse that b. Postural hypotension
18. A client seeks care because she feels depressed and can be life-threatening. To minimize these he frequently uses cocaine but that he can c. Confusion for a time after treatment
and has gained weight. To treat her atypical effects, opiate users are commonly detoxified control his use if he chooses. Which coping d. Complete loss of memory for a time
depression, the physician prescribes with: mechanism is he using? 33. A dying male client gradually moves toward
tranylcypromine sulfate (Parnate), 10 mg by a. Barbiturates a. Withdrawal resolution of feelings regarding impending
mouth twice per day. When this drug is used to b. Amphetamines b. Logical thinking death. Basing care on the theory of Kubler-Ross,
treat atypical depression, what is its onset of c. Methadone c. Repression Nurse Trish plans to use nonverbal interventions
action? d. Benzodiazepines d. Denial when assessment reveals that the client is in the:
a. 1 to 2 days a. Anger stage
b. 3 to 5 days 23. Nurse Cristina is caring for a client who 28. Richard is admitted with a diagnosis of b. Denial stage
c. 6 to 8 days experiences false sensory perceptions with no schizotypal personality disorder. hich signs c. Bargaining stage
d. 10 to 14 days basis in reality. These perceptions are known as: would this client exhibit during social situations? d. Acceptance stage
a. Delusions a. Aggressive behavior
19. A 65 years old client is in the first stage of b. Hallucinations b. Paranoid thoughts 34. The outcome that is unrelated to a crisis state is:
Alzheimer's disease. Nurse Patricia should plan c. Loose associations c. Emotional affect a. Learning more constructive coping skills
to focus this client's care on: d. Neologisms d. Independence needs b. Decompensation to a lower level of
a. Offering nourishing finger foods to help functioning.
maintain the client's nutritional status. 24. Nurse Marco is developing a plan of care for a 29. Nurse Mickey is caring for a client diagnosed c. Adaptation and a return to a prior level
b. Providing emotional support and client with anorexia nervosa. Which action with bulimia. The most appropriate initial goal of functioning.
individual counseling. should the nurse include in the plan? for a client diagnosed with bulimia is to: d. A higher level of anxiety continuing for
c. Monitoring the client to prevent minor a. Restricts visits with the family and a. Avoid shopping for large amounts of more than 3 months.
illnesses from turning into major friends until the client begins to eat. food.
problems. b. Provide privacy during meals. b. Control eating impulses. 35. Miranda a psychiatric client is to be discharged
d. Suggesting new activities for the client c. Set up a strict eating plan for the client. c. Identify anxiety-causing situations with orders for haloperidol (haldol) therapy.
and family to do together. d. Encourage the client to exercise, which d. Eat only three meals per day. When developing a teaching plan for discharge,
will reduce her anxiety. the nurse should include cautioning the client
20. The nurse is assessing a client who has just been 30. Rudolf is admitted for an overdose of against:
admitted to the emergency department. Which 25. Tim is admitted with a diagnosis of delusions of amphetamines. When assessing the client, the a. Driving at night
signs would suggest an overdose of an grandeur. The nurse is aware that this diagnosis nurse should expect to see: b. Staying in the sun
antianxiety agent? reflects a belief that one is: a. Tension and irritability c. Ingesting wines and cheeses
a. Combativeness, sweating, and confusion a. Highly important or famous. b. Slow pulse d. Taking medications containing aspirin
b. Agitation, hyperactivity, and grandiose b. Being persecuted c. Hypotension
ideation c. Connected to events unrelated to d. Constipation 36. Jen a nursing student is anxious about the
c. Emotional lability, euphoria, and oneself upcoming board examination but is able to study
impaired memory d. Responsible for the evil in the world. 31. Nicolas is experiencing hallucinations tells the intently and does not become distracted by a
d. Suspiciousness, dilated pupils, and nurse, “The voices are telling me I’m no good.” roommate’s talking and loud music. The
increased blood pressure 26. Nurse Jen is caring for a male client with manic The client asks if the nurse hears the voices. The student’s ability to ignore distractions and to
depression. The plan of care for a client in a most appropriate response by the nurse would focus on studying demonstrates:
21. The nurse is caring for a client diagnosed with manic state would include: be: a. Mild-level anxiety
antisocial personality disorder. The client has a a. Offering a high-calorie meals and a. “It is the voice of your conscience, which b. Panic-level anxiety
history of fighting, cruelty to animals, and strongly encouraging the client to finish only you can control.” c. Severe-level anxiety
stealing. Which of the following traits would the all food. b. “No, I do not hear your voices, but I d. Moderate-level anxiety
nurse be most likely to uncover during b. Insisting that the client remain active believe you can hear them”.
assessment? through the day so that he’ll sleep at c. “The voices are coming from within you 37. When assessing a premorbid personality
a. History of gainful employment night. and only you can hear them.” characteristic of a client with a major
b. Frequent expression of guilt regarding c. Allowing the client to exhibit d. “Oh, the voices are a symptom of your depression, it would be unusual for the nurse to
antisocial behavior hyperactive, demanding, manipulative illness; don’t pay any attention to them.” find that this client demonstrated:
c. Demonstrated ability to maintain close, behavior without setting limits. a. Rigidity
stable relationships b. Stubbornness
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c. Diverse interest b. "You're just doing this to get back at me 52. Mr. Cruz visits the physician's office to seek
d. Over meticulousness 43. When establishing an initial nurse-client for making you come to therapy." treatment for depression, feelings of
relationship, Nurse Hazel should explore with c. "Your cursing is interrupting the activity. hopelessness, poor appetite, insomnia, fatigue,
38. Nurse Krina recognizes that the suicidal risk for the client the: Take time out in your room for 10 low self- esteem, poor concentration, and
depressed client is greatest: a. Client’s perception of the presenting minutes." difficulty making decisions. The client states that
a. As their depression begins to improve problem. d. "I'm disappointed in you. You can't these symptoms began at least 2 years ago.
b. When their depression is most severe b. Occurrence of fantasies the client may control yourself even for a few minutes." Based on this report, the nurse Tyfany suspects:
c. Before any type of treatment is started experience. a. Cyclothymic disorder.
d. As they lose interest in the environment c. Details of any ritualistic acts carried out 48. Nurse Maureen knows that the nonantipsychotic b. Atypical affective disorder.
by the client medication used to treat some clients with c. Major depression.
39. Nurse Kate would expect that a client with d. Client’s feelings when external; controls schizoaffective disorder is: d. Dysthymic disorder.
vascular dementis would experience: are instituted. a. phenelzine (Nardil)
a. Loss of remote memory related to b. chlordiazepoxide (Librium) 53. After taking an overdose of phenobarbital
anoxia 44. Tranylcypromine sulfate (Parnate) is prescribed c. lithium carbonate (Lithane) (Barbita), Mario is admitted to the emergency
b. Loss of abstract thinking related to for a depressed client who has not responded to d. imipramine (Tofranil) department. Dr. Trinidad prescribes activated
emotional state the tricyclic antidepressants. After teaching the charcoal (Charcocaps) to be administered by
c. Inability to concentrate related to client about the medication, Nurse Marian 49. Which information is most important for the mouth immediately. Before administering the
decreased stimuli evaluates that learning has occurred when the nurse Trinity to include in a teaching plan for a dose, the nurse verifies the dosage ordered.
d. Disturbance in recalling recent events client states, “I will avoid: male schizophrenic client taking clozapine What is the usual minimum dose of activated
related to cerebral hypoxia. a. Citrus fruit, tuna, and yellow (Clozaril)? charcoal?
vegetables.” a. Monthly blood tests will be necessary. a. 5 g mixed in 250 ml of water
40. Josefina is to be discharged on a regimen of b. Chocolate milk, aged cheese, and b. Report a sore throat or fever to the b. 15 g mixed in 500 ml of water
lithium carbonate. In the teaching plan for yogurt’” physician immediately. c. 30 g mixed in 250 ml of water
discharge the nurse should include: c. Green leafy vegetables, chicken, and c. Blood pressure must be monitored for d. 60 g mixed in 500 ml of water
a. Advising the client to watch the diet milk.” hypertension.
carefully d. Whole grains, red meats, and d. Stop the medication when symptoms 54. What herbal medication for depression, widely
b. Suggesting that the client take the pills carbonated soda.” subside. used in Europe, is now being prescribed in the
with milk United States?
c. Reminding the client that a CBC must be 45. Nurse John is a aware that most crisis situations 50. Ricky with chronic schizophrenia takes a. Ginkgo biloba
done once a month. should resolve in about: neuroleptic medication is admitted to the b. Echinacea
d. Encouraging the client to have blood a. 1 to 2 weeks psychiatric unit. Nursing assessment reveals c. St. John's wort
levels checked as ordered. b. 4 to 6 weeks rigidity, fever, hypertension, and diaphoresis. d. Ephedra
c. 4 to 6 months These findings suggest which life- threatening
41. The psychiatrist orders lithium carbonate 600 d. 6 to 12 months reaction: 55. Cely with manic episodes is taking lithium.
mg p.o t.i.d for a female client. Nurse Katrina a. Tardive dyskinesia. Which electrolyte level should the nurse check
would be aware that the teachings about the 46. Nurse Judy knows that statistics show that in b. Dystonia. before administering this medication?
side effects of this drug were understood when adolescent suicide behavior: c. Neuroleptic malignant syndrome. a. Clcium
the client state, “I will call my doctor a. Females use more dramatic methods d. Akathisia. b. Sodium
immediately if I notice any: than males c. Chloride
a. Sensitivity to bright light or sun b. Males account for more attempts than 51. Which nursing intervention would be most d. Potassium
b. Fine hand tremors or slurred speech do females appropriate if a male client develop orthostatic
c. Sexual dysfunction or breast c. Females talk more about suicide before hypotension while taking amitriptyline (Elavil)? 56. Nurse Josefina is caring for a client who has been
enlargement attempting it a. Consulting with the physician about diagnosed with delirium. Which statement about
d. Inability to urinate or difficulty when d. Males are more likely to use lethal substituting a different type of delirium is true?
urinating methods than are females antidepressant. a. It's characterized by an acute onset and
b. Advising the client to sit up for 1 minute lasts about 1 month.
42. Nurse Mylene recognizes that the most 47. Dervid with paranoid schizophrenia repeatedly before getting out of bed. b. It's characterized by a slowly evolving
important factor necessary for the establishment uses profanity during an activity therapy session. c. Instructing the client to double the onset and lasts about 1 week.
of trust in a critical care area is: Which response by the nurse would be most dosage until the problem resolves. c. It's characterized by a slowly evolving
a. Privacy appropriate? d. Informing the client that this adverse onset and lasts about 1 month.
b. Respect a. "Your behavior won't be tolerated. Go to reaction should disappear within 1 d. It's characterized by an acute onset and
c. Empathy your room immediately." week. lasts hours to a number of days.
d. Presence
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57. Edward, a 66 year old client with slight memory 65. Nurse Irish is aware that Ritalin is the drug of a. Revealing personal information to the
impairment and poor concentration is diagnosed 61. Mr. Garcia, an attorney who throws books and choice for a child with ADHD. The side effects of client
with primary degenerative dementia of the furniture around the office after losing a case is the following may be noted by the nurse: b. Focusing on the feelings of the client.
Alzheimer's type. Early signs of this dementia referred to the psychiatric nurse in the law firm's a. Increased attention span and c. Confronting the client about
include subtle personality changes and employee assistance program. Nurse Beatriz concentration discrepancies in verbal or non-verbal
withdrawal from social interactions. To assess knows that the client's behavior most likely b. Increase in appetite behavior
for progression to the middle stage of represents the use of which defense c. Sleepiness and lethargy d. The client feels angry towards the nurse
Alzheimer's disease, the nurse should observe mechanism? d. Bradycardia and diarrhea who resembles his mother.
the client for: a. Regression
a. Occasional irritable outbursts. b. Projection 66. Kitty, a 9 year old child has very limited 72. Tristan is on Lithium has suffered from diarrhea
b. Impaired communication. c. Reaction-formation vocabulary and interaction skills. She has an I.Q. and vomiting. What should the nurse in-charge
c. Lack of spontaneity. d. Intellectualization of 45. She is diagnosed to have Mental do first:
d. Inability to perform self-care activities. retardation of this classification: a. Recognize this as a drug interaction
62. Nurse Anne is caring for a client who has been a. Profound b. Give the client Cogentin
58. Isabel with a diagnosis of depression is started treated long term with antipsychotic medication. b. Mild c. Reassure the client that these are
on imipramine (Tofranil), 75 mg by mouth at During the assessment, Nurse Anne checks the c. Moderate common side effects of lithium therapy
bedtime. The nurse should tell the client that: client for tardive dyskinesia. If tardive dyskinesia d. Severe d. Hold the next dose and obtain an order
a. This medication may be habit forming is present, Nurse Anne would most likely for a stat serum lithium level
and will be discontinued as soon as the observe: 67. The therapeutic approach in the care of Armand
client feels better. a. Abnormal movements and involuntary an autistic child include the following EXCEPT: 73. Nurse Sarah ensures a therapeutic environment
b. This medication has no serious adverse movements of the mouth, tongue, and a. Engage in diversionary activities when for all the client. Which of the following best
effects. face. acting -out describes a therapeutic milieu?
c. The client should avoid eating such b. Abnormal breathing through the nostrils b. Provide an atmosphere of acceptance a. A therapy that rewards adaptive
foods as aged cheeses, yogurt, and accompanied by a “thrill.” c. Provide safety measures behavior
chicken livers while taking the c. Severe headache, flushing, tremors, and d. Rearrange the environment to activate b. A cognitive approach to change behavior
medication. ataxia. the child c. A living, learning or working
d. This medication may initially cause d. Severe hypertension, migraine environment.
tiredness, which should become less headache, 68. Jeremy is brought to the emergency room by d. A permissive and congenial environment
bothersome over time. friends who state that he took something an
63. Dennis has a lithium level of 2.4 mEq/L. The hour ago. He is actively hallucinating, agitated, 74. Anthony is very hostile toward one of the staff
59. Kathleen is admitted to the psychiatric clinic for nurse immediately would assess the client for with irritated nasal septum. for no apparent reason. He is manifesting:
treatment of anorexia nervosa. To promote the which of the following signs or symptoms? a. Heroin a. Splitting
client's physical health, the nurse should plan to: a. Weakness b. Cocaine b. Transference
a. Severely restrict the client's physical b. Diarrhea c. LSD c. Countertransference
activities. c. Blurred vision d. Marijuana d. Resistance
b. Weigh the client daily, after the evening d. Fecal incontinence
meal. 69. Nurse Pauline is aware that Dementia unlike 75. Marielle, 17 years old was sexually attacked
c. Monitor vital signs, serum electrolyte 64. Nurse Jannah is monitoring a male client who delirium is characterized by: while on her way home from school. She is
levels, and acid-base balance. has been placed inrestraints because of violent a. Slurred speech brought to the hospital by her mother. Rape is
d. Instruct the client to keep an accurate behavior. Nurse determines that it will be safe to b. Insidious onset an example of which type of crisis:
record of food and fluid intake. remove the restraints when: c. Clouding of consciousness a. Situational
a. The client verbalizes the reasons for the d. Sensory perceptual change b. Adventitious
60. Celia with a history of polysubstance abuse is violent behavior. c. Developmental
admitted to the facility. She complains of nausea b. The client apologizes and tells the nurse 70. A 35 year old female has intense fear of riding an d. Internal
and vomiting 24 hours after admission. The that it will never happen again. elevator. She claims “ As if I will die inside.” The
nurse assesses the client and notes piloerection, c. No acts of aggression have been client is suffering from: 76. Nurse Greta is aware that the following is
pupillary dilation, and lacrimation. The nurse observed within 1 hour after the release a. Agoraphobia classified as an Axis I disorder by the Diagnosis
suspects that the client is going through which of of two of the extremity restraints. b. Social phobia and Statistical Manual of Mental Disorders, Text
the following withdrawals? d. The administered medication has taken c. Claustrophobia Revision (DSM-IV-TR) is:
a. Alcohol withdrawal effect. d. Xenophobia a. Obesity
b. Cannibis withdrawal b. Borderline personality disorder
c. Cocaine withdrawal 71. Nurse Myrna develops a counter-transference c. Major depression
d. Opioid withdrawal reaction. This is evidenced by: d. Hypertension
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d. It promotes emotional support or 86. Ricardo, an outpatient in psychiatric facility is c. The client becomes anxious whenever
77. Katrina, a newly admitted is extremely hostile attention for the client diagnosed with dysthymic disorder. Which of the the nurse leaves the bedside
toward a staff member she has just met, without following statement about dysthymic disorder is d. The client looks at the shadow on a wall
apparent reason. According to Freudian theory, 82. Dervid is diagnosed with panic disorder with true? and tells the nurse she sees frightening
the nurse should suspect that the client is agoraphobia is talking with the nurse in-charge a. It involves a mood range from moderate faces on the wall.
experiencing which of the following about the progress made in treatment. Which of depression to hypomania
phenomena? the following statements indicates a positive b. It involves a single manic depression 91. During conversation of Nurse John with a client,
a. Intellectualization client response? c. It’s a form of depression that occurs in he observes that the client shift from one topic
b. Transference a. “I went to the mall with my friends last the fall and winter to the next on a regular basis. Which of the
c. Triangulation Saturday” d. It’s a mood disorder similar to major following terms describes this disorder?
d. Splitting b. “I’m hyperventilating only when I have a depression but of mild to moderate a. Flight of ideas
panic attack” severity b. Concrete thinking
78. An 83year-old male client is in extended care c. “Today I decided that I can stop taking c. Ideas of reference
facility is anxious most of the time and my medication” 87. The nurse is aware that the following ways in d. Loose association
frequently complains of a number of vague d. “Last night I decided to eat more than a vascular dementia different from Alzheimer’s
symptoms that interfere with his ability to eat. bowl of cereal” disease is: 92. Francis tells the nurse that her coworkers are
These symptoms indicate which of the following a. Vascular dementia has more abrupt sabotaging the computer. When the nurse asks
disorders? 83. The effectiveness of monoamine oxidase (MAO) onset questions, the client becomes argumentative.
a. Conversion disorder inhibitor drug therapy in a client with b. The duration of vascular dementia is This behavior shows personality traits associated
b. Hypochondriasis posttraumatic stress disorder can be usually brief with which of the following personality disorder?
c. Severe anxiety demonstrated by which of the following client c. Personality change is common in a. Antisocial
d. Sublimation self –reports? vascular dementia b. Histrionic
a. “I’m sleeping better and don’t have d. The inability to perform motor activities c. Paranoid
79. Charina, a college student who frequently visited nightmares” occurs in vascular dementia d. Schizotypal
the health center during the past year with b. “I’m not losing my temper as much”
multiple vague complaints of GI symptoms c. “I’ve lost my craving for alcohol” 88. Loretta, a newly admitted client was diagnosed 93. Which of the following interventions is
before course examinations. Although physical d. I’ve lost my phobia for water” with delirium and has history of hypertension important for a Cely experiencing with paranoid
causes have been eliminated, the student and anxiety. She had been taking digoxin, personality disorder taking olanzapine
continues to express her belief that she has a 84. Mark, with a diagnosis of generalized anxiety furosemide (Lasix), and diazepam (Valium) for (Zyprexa)?
serious illness. These symptoms are typically of disorder wants to stop taking his lorazepam anxiety. This client’s impairment may be related a. Explain effects of serotonin syndrome
which of the following disorders? (Ativan). Which of the following important facts to which of the following conditions? b. Teach the client to watch for
a. Conversion disorder should nurse Betty discuss with the client about a. Infection extrapyramidal adverse reaction
b. Depersonalization discontinuing the medication? b. Metabolic acidosis c. Explain that the drug is less affective if
c. Hypochondriasis a. Stopping the drug may cause depression c. Drug intoxication the client smokes
d. Somatization disorder b. Stopping the drug increases cognitive d. Hepatic encephalopathy d. Discuss the need to report paradoxical
abilities effects such as euphoria
80. Nurse Daisy is aware that the following c. Stopping the drug decreases sleeping 89. Nurse Ron enters a client’s room, the client says,
pharmacologic agents are sedative- hypnotic difficulties “They’re crawling on my sheets! Get them off 94. Nurse Alexandra notices other clients on the unit
medication is used to induce sleep for a client d. Stopping the drug can cause withdrawal my bed!” Which of the following assessment is avoiding a client diagnosed with antisocial
experiencing a sleep disorder is: symptoms the most accurate? personality disorder. When discussing
a. Triazolam (Halcion) a. The client is experiencing aphasia appropriate behavior in group therapy, which of
b. Paroxetine (Paxil)\ 85. Jennifer, an adolescent who is depressed and b. The client is experiencing dysarthria the following comments is expected about this
c. Fluoxetine (Prozac) reported by his parents as having difficulty in c. The client is experiencing a flight of ideas client by his peers?
d. Risperidone (Risperdal) school is brought to the community mental d. The client is experiencing visual a. Lack of honesty
health center to be evaluated. Which of the hallucination b. Belief in superstition
81. Aldo, with a somatoform pain disorder may following other health problems would the nurse c. Show of temper tantrums
obtain secondary gain. Which of the following suspect? 90. Which of the following descriptions of a client’s d. Constant need for attention
statement refers to a secondary gain? a. Anxiety disorder experience and behavior can be assessed as an
a. It brings some stability to the family b. Behavioral difficulties illusion? 95. Tommy, with dependent personality disorder is
b. It decreases the preoccupation with the c. Cognitive impairment a. The client tries to hit the nurse when working to increase his self- esteem. Which of
physical illness d. Labile moods vital signs must be taken the following statements by the Tommy shows
c. It enables the client to avoid some b. The client says, “I keep hearing a voice teaching was successful?
unpleasant activity telling me to run away”
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a. “I’m not going to look just at the 100. Rocky has started taking haloperidol (Haldol). Answers and Rationale – Care of Clients with Rationale: This behavior is an example of
negative things about myself” Which of the following instructions is most Physiologic and Psychosocial Alterations reaction formation, a coping mechanism.
b. “I’m most concerned about my level of appropriate for Ricky before taking 11. Answer: (A) By designating times during which
competence and progress” haloperidol? 1. Answer: (D) Focusing the client can focus on the behavior.
c. “I’m not as envious of the things other a. Should report feelings of restlessness or Rationale: The nurse is using focusing by Rationale: The nurse should designate times
people have as I used to be” agitation at once suggesting that the client discuss a specific issue. during which the client can focus on the
d. “I find I can’t stop myself from taking b. Use a sunscreen outdoors on a year- The nurse didn’t restate the question, make compulsive behavior or obsessive thoughts. The
over things other should be doing” round basis observation, or ask further question (exploring). nurse should urge the client to reduce the
c. Be aware you’ll feel increased energy 2. Answer: (D) Remove all other clients from the frequency of the compulsive behavior gradually,
96. Norma, a 42-year-old client with a diagnosis of taking this drug dayroom. not rapidly. She shouldn't call attention to or try
chronic undifferentiated schizophrenia lives in a d. This drug will indirectly control essential Rationale: The nurse’s first priority is to consider to prevent the behavior. Trying to prevent the
rooming house that has a weekly nursing clinic. hypertension the safety of the clients in the therapeutic behavior may cause pain and terror in the client.
She scratches while she tells the nurse she feels setting. The other actions are appropriate The nurse should encourage the client to
creatures eating away at her skin. Which of the responses after ensuring the safety of other verbalize anxieties to help distract attention
following interventions should be done first? clients. from the compulsive behavior.
a. Talk about his hallucinations and fears 3. Answer: (A) The client is disruptive. 12. Answer: (D) Exploring the meaning of the
b. Refer him for anticholinergic adverse Rationale: Group activity provides too much traumatic event with the client.
reactions stimulation, which the client will not be able to Rationale: The client with PTSD needs
c. Assess for possible physical problems handle (harmful to self) and as a result will be encouragement to examine and understand the
such as rash disruptive to others. meaning of the traumatic event and consequent
d. Call his physician to get his medication 4. Answer: (C) Agree to talk with the mother and losses. Otherwise, symptoms may worsen and
increased to control his psychosis the father together. the client may become depressed or engage in
Rationale: By agreeing to talk with both parents, self-destructive behavior such as substance
97. Ivy, who is on the psychiatric unit is copying and the nurse can provide emotional support and abuse. The client must explore the meaning of
imitating the movements of her primary nurse. further assess and validate the family’s needs. the event and won't heal without this, no matter
During recovery, she says, “I thought the nurse 5. Answer: (A) Perceptual disorders. how much time passes. Behavioral techniques,
was my mirror. I felt connected only when I saw Rationale: Frightening visual hallucinations are such as relaxation therapy, may help decrease
my nurse.” This behavior is known by which of especially common in clients experiencing the client's anxiety and induce sleep. The
the following terms? alcohol withdrawal. physician may prescribe antianxiety agents or
a. Modeling 6. Answer: (D) Suggest that it takes a while before antidepressants cautiously to avoid dependence;
b. Echopraxia seeing the results. sleep medication is rarely appropriate. A special
c. Ego-syntonicity Rationale: The client needs a specific response; diet isn't indicated unless the client also has an
d. Ritualism that it takes 2 to 3 weeks (a delayed effect) until eating disorder or a nutritional problem.
the therapeutic blood level is reached. 13. Answer: (C) "Your problem is real but there is no
98. Jun approaches the nurse and tells that he hears 7. Answer: (C) Superego physical basis for it. We'll work on what is going
a voice telling him that he’s evil and deserves to Rationale: This behavior shows a weak sense of on in your life to find out why it's happened."
die. Which of the following terms describes the moral consciousness. According to Freudian Rationale: The nurse must be honest with the
client’s perception? theory, personality disorders stem from a weak client by telling her that the paralysis has no
a. Delusion superego. physiologic cause while also conveying empathy
b. Disorganized speech 8. Answer: (C) Skeletal muscle paralysis. and acknowledging that her symptoms are real.
c. Hallucination Rationale: Anectine is a depolarizing muscle The client will benefit from psychiatric
d. Idea of reference relaxant causing paralysis. It is used to reduce treatment, which will help her understand the
the intensity of muscle contractions during the underlying cause of her symptoms. After the
99. Mike is admitted to a psychiatric unit with a convulsive stage, thereby reducing the risk of psychological conflict is resolved, her symptoms
diagnosis of undifferentiated schizophrenia. bone fractures or dislocation. will disappear. Saying that it must be awful not
Which of the following defense mechanisms is 9. Answer: (D) Increase calories, carbohydrates, to be able to move her legs wouldn't answer the
probably used by mike? and protein. client's question; knowing that the cause is
a. Projection Rationale: This client increased protein for tissue psychological wouldn't necessarily make her feel
b. Rationalization building and increased calories to replace what is better. Telling her that she has developed
c. Regression burned up (usually via carbohydrates). paralysis to avoid leaving her parents or that her
d. Repression 10. Answer: (C) Acting overly solicitous toward the personality caused her disorder wouldn't help
child. her understand and resolve the underlying
conflict.
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14. Answer: (C) fluvoxamine (Luvox) and Rationale: Clients in the first stage of Alzheimer's accepts as real. Loose associations are rapid behavior is uncommon, although these clients
clomipramine (Anafranil) disease are aware that something is happening shifts among unrelated ideas. Neologisms are may experience agitation with anxiety. Their
Rationale: The antidepressants fluvoxamine and to them and may become overwhelmed and bizarre words that have meaning only to the behavior is emotionally cold with a flattened
clomipramine have been effective in the frightened. Therefore, nursing care typically client. affect, regardless of the situation. These clients
treatment of OCD. Librium and Valium may be focuses on providing emotional support and 24. Answer: (C) Set up a strict eating plan for the demonstrate a reduced capacity for close or
helpful in treating anxiety related to OCD but individual counseling. The other options are client. dependent relationships.
aren't drugs of choice to treat the illness. The appropriate during the second stage of Rationale: Establishing a consistent eating plan 29. Answer: (C) Identify anxiety-causing situations
other medications mentioned aren't effective in Alzheimer's disease, when the client needs and monitoring the client’s weight are very Rationale: Bulimic behavior is generally a
the treatment of OCD. continuous monitoring to prevent minor important in this disorder. The family and friends maladaptive coping response to stress and
15. Answer: (A) A warning about the drugs delayed illnesses from progressing into major problems should be included in the client’s care. The client underlying issues. The client must identify
therapeutic effect, which is from 14 to 30 days. and when maintaining adequate nutrition may should be monitored during meals-not given anxiety-causing situations that stimulate the
Rationale: The client should be informed that become a challenge. During this stage, offering privacy. Exercise must be limited and supervised. bulimic behavior and then learn new ways of
the drug's therapeutic effect might not be nourishing finger foods helps clients to feed 25. Answer: (A) Highly important or famous. coping with the anxiety.
reached for 14 to 30 days. The client must be themselves and maintain adequate nutrition. Rationale: A delusion of grandeur is a false belief 30. Answer: (A) Tension and irritability
instructed to continue taking the drug as 20. Answer: (C) Emotional lability, euphoria, and that one is highly important or famous. A Rationale: An amphetamine is a nervous system
directed. Blood level checks aren't necessary. impaired memory delusion of persecution is a false belief that one stimulant that is subject to abuse because of its
NMS hasn't been reported with this drug, but Rationale: Signs of antianxiety agent overdose is being persecuted. A delusion of reference is a ability to produce wakefulness and euphoria. An
tachycardia is frequently reported. include emotional lability, euphoria, and false belief that one is connected to events overdose increases tension and irritability.
16. Answer: (B) Severe anxiety and fear. impaired memory. Phencyclidine overdose can unrelated to oneself or a belief that one is Options B and C are incorrect because
Rationale: Phobias cause severe anxiety (such as cause combativeness, sweating, and confusion. responsible for the evil in the world. amphetamines stimulate norepinephrine, which
a panic attack) that is out of proportion to the Amphetamine overdose can result in agitation, 26. Answer: (D) Listening attentively with a neutral increase the heart rate and blood flow. Diarrhea
threat of the feared object or situation. Physical hyperactivity, and grandiose ideation. attitude and avoiding power struggles. is a common adverse effect so option D is
signs and symptoms of phobias include profuse Hallucinogen overdose can produce Rationale: The nurse should listen to the client’s incorrect.
sweating, poor motor control, tachycardia, and suspiciousness, dilated pupils, and increased requests, express willingness to seriously 31. Answer: (B) “No, I do not hear your voices, but I
elevated blood pressure. Insomnia, an inability blood pressure. consider the request, and respond later. The believe you can hear them”.
to concentrate, and weight loss are common in 21. Answer: (D) A low tolerance for frustration nurse should encourage the client to take short Rationale: The nurse, demonstrating knowledge
depression. Withdrawal and failure to Rationale: Clients with an antisocial personality daytime naps because he expends so much and understanding, accepts the client’s
distinguish reality from fantasy occur in disorder exhibit a low tolerance for frustration, energy. The nurse shouldn’t try to restrain the perceptions even though they are hallucinatory.
schizophrenia. emotional immaturity, and a lack of impulse client when he feels the need to move around as 32. Answer: (C) Confusion for a time after treatment
17. Answer: (A) Antidepressants control. They commonly have a history of long as his activity isn’t harmful. High calorie Rationale: The electrical energy passing through
Rationale: Tricyclic and monoamine oxidase unemployment, miss work repeatedly, and quit finger foods should be offered to supplement the cerebral cortex during ECT results in a
(MAO) inhibitor antidepressants have been work without other plans for employment. They the client’s diet, if he can’t remain seated long temporary state of confusion after treatment.
found to be effective in treating clients with don't feel guilt about their behavior and enough to eat a complete meal. The nurse 33. Answer: (D) Acceptance stage
panic attacks. Why these drugs help control commonly perceive themselves as victims. They shouldn’t be forced to stay seated at the table to Rationale: Communication and intervention
panic attacks isn't clearly understood. also display a lack of responsibility for the finid=sh a meal. The nurse should set limits in a during this stage are mainly nonverbal, as when
Anticholinergic agents, which are smooth- outcome of their actions. Because of a lack of calm, clear, and self-confident tone of voice. the client gestures to hold the nurse’s hand.
muscle relaxants, relieve physical symptoms of trust in others, clients with antisocial personality 27. Answer: (D) Denial 34. Answer: (D) A higher level of anxiety continuing
anxiety but don't relieve the anxiety itself. disorder commonly have difficulty developing Rationale: Denial is unconscious defense for more than 3 months.
Antipsychotic drugs are inappropriate because stable, close relationships. mechanism in which emotional conflict and Rationale: This is not an expected outcome of a
clients who experience panic attacks aren't 22. Answer: (C) Methadone anxiety is avoided by refusing to acknowledge crisis because by definition a crisis would be
psychotic. Mood stabilizers aren't indicated Rationale: Methadone is used to detoxify opiate feelings, desires, impulses, or external facts that resolved in 6 weeks.
because panic attacks are rarely associated with users because it binds with opioid receptors at are consciously intolerable. Withdrawal is a 35. Answer: (B) Staying in the sun
mood changes. many sites in the central nervous system but common response to stress, characterized by Rationale: Haldol causes photosensitivity. Severe
18. Answer: (B) 3 to 5 days doesn’t have the same deterious effects as other apathy. Logical thinking is the ability to think sunburn can occur on exposure to the sun.
Rationale: Monoamine oxidase inhibitors, such opiates, such as cocaine, heroin, and morphine. rationally and make responsible decisions, which 36. Answer: (D) Moderate-level anxiety
as tranylcypromine, have an onset of action of Barbiturates, amphetamines, and would lead the client admitting the problem and Rationale: A moderately anxious person can
approximately 3 to 5 days. A full clinical benzodiazepines are highly addictive and would seeking help. Repression is suppressing past ignore peripheral events and focuses on central
response may be delayed for 3 to 4 weeks. The require detoxification treatment. events from the consciousness because of guilty concerns.
therapeutic effects may continue for 1 to 2 23. Answer: (B) Hallucinations association. 37. Answer: (C) Diverse interest
weeks after discontinuation. Rationale: Hallucinations are visual, auditory, 28. Answer: (B) Paranoid thoughts Rationale: Before onset of depression, these
19. Answer: (B) Providing emotional support and gustatory, tactile, or olfactory perceptions that Rationale: Clients with schizotypal personality clients usually have very narrow, limited
individual counseling. have no basis in reality. Delusions are false disorder experience excessive social anxiety that interest.
beliefs, rather than perceptions, that the client can lead to paranoid thoughts. Aggressive
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38. Answer: (A) As their depression begins to option A. Option B is incorrect because it implies the nurse should advise the client to sit up for 1 functions but sodium is most important to the
improve that the client’s actions reflect feelings toward minute before getting out of bed. Orthostatic absorption of lithium.
Rationale: At this point the client may have the staff instead of the client's own misery. hypotension commonly occurs with tricyclic 56. Answer: (D) It's characterized by an acute onset
enough energy to plan and execute an attempt. Judgmental remarks, such as option D, may antidepressant therapy. In these cases, the and lasts hours to a number of days
39. Answer: (D) Disturbance in recalling recent decrease the client's self-esteem. dosage may be reduced or the physician may Rationale: Delirium has an acute onset and
events related to cerebral hypoxia. 48. Answer: (C) lithium carbonate (Lithane) prescribe nortriptyline, another tricyclic typically can last from several hours to several
Rationale: Cell damage seems to interfere with Rationale: Lithium carbonate, an antimania drug, antidepressant. Orthostatic hypotension days.
registering input stimuli, which affects the ability is used to treat clients with cyclical disappears only when the drug is discontinued. 57. Answer: (B) Impaired communication.
to register and recall recent events; vascular schizoaffective disorder, a psychotic disorder 52. Answer: (D) Dysthymic disorder. Rationale: Initially, memory impairment may be
dementia is related to multiple vascular lesions once classified under schizophrenia that causes Rationale: Dysthymic disorder is marked by the only cognitive deficit in a client with
of the cerebral cortex and subcortical structure. affective symptoms, including maniclike activity. feelings of depression lasting at least 2 years, Alzheimer's disease. During the early stage of
40. Answer: (D) Encouraging the client to have blood Lithium helps control the affective component of accompanied by at least two of the following this disease, subtle personality changes may also
levels checked as ordered. this disorder. Phenelzine is a monoamine symptoms: sleep disturbance, appetite be present. However, other than occasional
Rationale: Blood levels must be checked monthly oxidase inhibitor prescribed for clients who don't disturbance, low energy or fatigue, low self- irritable outbursts and lack of spontaneity, the
or bimonthly when the client is on maintenance respond to other antidepressant drugs such as esteem, poor concentration, difficulty making client is usually cooperative and exhibits socially
therapy because there is only a small range imipramine. Chlordiazepoxide, an antianxiety decisions, and hopelessness. These symptoms appropriate behavior. Signs of advancement to
between therapeutic and toxic levels. agent, generally is contraindicated in psychotic may be relatively continuous or separated by the middle stage of Alzheimer's disease include
41. Answer: (B) Fine hand tremors or slurred speech clients. Imipramine, primarily considered an intervening periods of normal mood that last a exacerbated cognitive impairment with obvious
Rationale: These are common side effects of antidepressant agent, is also used to treat clients few days to a few weeks. Cyclothymic disorder is personality changes and impaired
lithium carbonate. with agoraphobia and that undergoing cocaine a chronic mood disturbance of at least 2 years' communication, such as inappropriate
42. Answer: (D) Presence detoxification. duration marked by numerous periods of conversation, actions, and responses. During the
Rationale: The constant presence of a nurse 49. Answer: (B) Report a sore throat or fever to the depression and hypomania. Atypical affective late stage, the client can't perform self-care
provides emotional support because the client physician immediately. disorder is characterized by manic signs and activities and may become mute.
knows that someone is attentive and available in Rationale: A sore throat and fever are symptoms. Major depression is a recurring, 58. Answer: (D) This medication may initially cause
case of an emergency. indications of an infection caused by persistent sadness or loss of interest or pleasure tiredness, which should become less
43. Answer: (A) Client’s perception of the presenting agranulocytosis, a potentially life-threatening in almost all activities, with signs and symptoms bothersome over time.
problem. complication of clozapine. Because of the risk of recurring for at least 2 weeks. Rationale: Sedation is a common early adverse
Rationale: The nurse can be most therapeutic by agranulocytosis, white blood cell (WBC) counts 53. Answer: (C) 30 g mixed in 250 ml of water effect of imipramine, a tricyclic antidepressant,
starting where the client is, because it is the are necessary weekly, not monthly. If the WBC Rationale: The usual adult dosage of activated and usually decreases as tolerance develops.
client’s concept of the problem that serves as count drops below 3,000/μl, the medication charcoal is 5 to 10 times the estimated weight of Antidepressants aren't habit forming and don't
the starting point of the relationship. must be stopped. Hypotension may occur in the drug or chemical ingested, or a minimum cause physical or psychological dependence.
44. Answer: (B) Chocolate milk, aged cheese, and clients taking this medication. Warn the client to dose of 30 g, mixed in 250 ml of water. Doses However, after a long course of high-dose
yogurt’” stand up slowly to avoid dizziness from less than this will be ineffective; doses greater therapy, the dosage should be decreased
Rationale: These high-tyramine foods, when orthostatic hypotension. The medication should than this can increase the risk of adverse gradually to avoid mild withdrawal symptoms.
ingested in the presence of an MAO inhibitor, be continued, even when symptoms have been reactions, although toxicity doesn't occur with Serious adverse effects, although rare, include
cause a severe hypertensive response. controlled. If the medication must be stopped, it activated charcoal, even at the maximum dose. myocardial infarction, heart failure, and
45. Answer: (B) 4 to 6 weeks should be slowly tapered over 1 to 2 weeks and 54. Answer: (C) St. John's wort tachycardia. Dietary restrictions, such as
Rationale: Crisis is self-limiting and lasts from 4 only under the supervision of a physician. Rationale: St. John's wort has been found to avoiding aged cheeses, yogurt, and chicken
to 6 weeks. 50. Answer: (C) Neuroleptic malignant syndrome. have serotonin-elevating properties, similar to livers, are necessary for a client taking a
46. Answer: (D) Males are more likely to use lethal Rationale: The client's signs and symptoms prescription antidepressants. Ginkgo biloba is monoamine oxidase inhibitor, not a tricyclic
methods than are females suggest neuroleptic malignant syndrome, a life- prescribed to enhance mental acuity. Echinacea antidepressant.
Rationale: This finding is supported by research; threatening reaction to neuroleptic medication has immune-stimulating properties. Ephedra is a 59. Answer: (C) Monitor vital signs, serum
females account for 90% of suicide attempts but that requires immediate treatment. Tardive naturally occurring stimulant that is similar to electrolyte levels, and acid-base balance.
males are three times more successful because dyskinesia causes involuntary movements of the ephedrine. Rationale: An anorexic client who requires
of methods used. tongue, mouth, facial muscles, and arm and leg 55. Answer: (B) Sodium hospitalization is in poor physical condition from
47. Answer: (C) "Your cursing is interrupting the muscles. Dystonia is characterized by cramps Rationale: Lithium is chemically similar to starvation and may die as a result of
activity. Take time out in your room for 10 and rigidity of the tongue, face, neck, and back sodium. If sodium levels are reduced, such as arrhythmias, hypothermia, malnutrition,
minutes." muscles. Akathisia causes restlessness, anxiety, from sweating or diuresis, lithium will be infection, or cardiac abnormalities secondary to
Rationale: The nurse should set limits on client and jitteriness. reabsorbed by the kidneys, increasing the risk of electrolyte imbalances. Therefore, monitoring
behavior to ensure a comfortable environment 51. Answer: (B) Advising the client to sit up for 1 toxicity. Clients taking lithium shouldn't restrict the client's vital signs, serum electrolyte level,
for all clients. The nurse should accept hostile or minute before getting out of bed. their intake of sodium and should drink and acid base balance is crucial. Option A may
quarrelsome client outbursts within limits Rationale: To minimize the effects of adequate amounts of fluid each day. The other worsen anxiety. Option B is incorrect because a
without becoming personally offended, as in amitriptyline-induced orthostatic hypotension, electrolytes are important for normal body weight obtained after breakfast is more accurate
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than one obtained after the evening meal. 65. Answer: (A) increased attention span and unconscious needs and conflicts. B and C. These Rationale: The DSM-IV-TR classifies major
Option D would reward the client with attention concentration are therapeutic approaches. D. This is depression as an Axis I disorder. Borderline
for not eating and reinforce the control issues Rationale: The medication has a paradoxic effect transference reaction where a client has an personality disorder as an Axis II; obesity and
that are central to the underlying psychological that decreases hyperactivity and impulsivity emotional reaction towards the nurse based on hypertension, Axis III.
problem; also, the client may record food and among children with ADHD. B, C, D. Side effects her past. 77. Answer: (B) Transference
fluid intake inaccurately. of Ritalin include anorexia, insomnia, diarrhea 72. Answer: (D) Hold the next dose and obtain an Rationale: Transference is the unconscious
60. Answer: (D) Opioid withdrawal and irritability. order for a stat serum lithium level assignment of negative or positive feelings
Rationale: The symptoms listed are specific to 66. Answer: (C) Moderate Rationale: Diarrhea and vomiting are evoked by a significant person in the client’s past
opioid withdrawal. Alcohol withdrawal would Rationale: The child with moderate mental manifestations of Lithium toxicity. The next dose to another person. Intellectualization is a
show elevated vital signs. There is no real retardation has an I.Q. of 35- 50 Profound of lithium should be withheld and test is done to defense mechanism in which the client avoids
withdrawal from cannibis. Symptoms of cocaine Mental retardation has an I.Q. of below 20; Mild validate the observation. A. The manifestations dealing with emotions by focusing on facts.
withdrawal include depression, anxiety, and mental retardation 50-70 and Severe mental are not due to drug interaction. B. Cogentin is Triangulation refers to conflicts involving three
agitation. retardation has an I.Q. of 20-35. used to manage the extra pyramidal symptom family members. Splitting is a defense
61. Answer: (A) Regression 67. Answer: (D) Rearrange the environment to side effects of antipsychotics. C. The common mechanism commonly seen in clients with
Rationale: An adult who throws temper activate the child side effects of Lithium are fine hand tremors, personality disorder in which the world is
tantrums, such as this one, is displaying Rationale: The child with autistic disorder does nausea, polyuria and polydipsia. perceived as all good or all bad.
regressive behavior, or behavior that is not want change. Maintaining a consistent 73. Answer: (C) A living, learning or working 78. Answer: (B) Hypochondriasis
appropriate at a younger age. In projection, the environment is therapeutic. A. Angry outburst environment. Rationale: Complains of vague physical
client blames someone or something other than can be re-channeling through safe activities. B. Rationale: A therapeutic milieu refers to a broad symptoms that have no apparent medical causes
the source. In reaction formation, the client acts Acceptance enhances a trusting relationship. C. conceptual approach in which all aspects of the are characteristic of clients with
in opposition to his feelings. In Ensure safety from self-destructive behaviors environment are channeled to provide a hypochondriasis. In many cases, the GI system is
intellectualization, the client overuses rational like head banging and hair pulling. therapeutic environment for the client. The six affected. Conversion disorders are characterized
explanations or abstract thinking to decrease the 68. Answer: (B) cocaine environmental elements include structure, by one or more neurologic symptoms. The
significance of a feeling or event. Rationale: The manifestations indicate safety, norms; limit setting, balance and unit client’s symptoms don’t suggest severe anxiety.
62. Answer: (A) Abnormal movements and intoxication with cocaine, a CNS stimulant. A. modification. A. Behavioral approach in A client experiencing sublimation channels
involuntary movements of the mouth, tongue, Intoxication with heroine is manifested by psychiatric care is based on the premise that maladaptive feelings or impulses into socially
and face. euphoria then impairment in judgment, behavior can be learned or unlearned through acceptable behavior
Rationale: Tardive dyskinesia is a severe reaction attention and the presence of papillary the use of reward and punishment. B. Cognitive 79. Answer: (C) Hypochondriasis
associated with long term use of antipsychotic constriction. C. Intoxication with hallucinogen approach to change behavior is done by Rationale: Hypochodriasis in this case is shown
medication. The clinical manifestations include like LSD is manifested by grandiosity, correcting distorted perceptions and irrational by the client’s belief that she has a serious
abnormal movements (dyskinesia) and hallucinations, synesthesia and increase in vital beliefs to correct maladaptive behaviors. D. This illness, although pathologic causes have been
involuntary movements of the mouth, tongue signs D. Intoxication with Marijuana, a is not congruent with therapeutic milieu. eliminated. The disturbance usually lasts at least
(fly catcher tongue), and face. cannabinoid is manifested by sensation of 74. Answer: (B) Transference 6 with identifiable life stressor such as, in this
63. Answer: (C) Blurred vision slowed time, conjunctival redness, social Rationale: Transference is a positive or negative case, course examinations. Conversion disorders
Rationale: At lithium levels of 2 to 2.5 mEq/L the withdrawal, impaired judgment and feeling associated with a significant person in are characterized by one or more neurologic
client will experienced blurred vision, muscle hallucinations. the client’s past that are unconsciously assigned symptoms. Depersonalization refers to
twitching, severe hypotension, and persistent 69. Answer: (B) insidious onset to another A. Splitting is a defense mechanism persistent recurrent episodes of feeling
nausea and vomiting. With levels between 1.5 Rationale: Dementia has a gradual onset and commonly seen in a client with personality detached from one’s self or body. Somatoform
and 2 mEq/L the client experiencing vomiting, progressive deterioration. It causes pronounced disorder in which the world is perceived as all disorders generally have a chronic course with
diarrhea, muscle weakness, ataxia, dizziness, memory and cognitive disturbances. A,C and D good or all bad C. Countert-transference is a few remissions.
slurred speech, and confusion. At lithium levels are all characteristics of delirium. phenomenon where the nurse shifts feelings 80. Answer: (A) Triazolam (Halcion)
of 2.5 to 3 mEq/L or higher, urinary and fecal 70. Answer: (C) Claustrophobia assigned to someone in her past to the patient Rationale: Triazolam is one of a group of
incontinence occurs, as well as seizures, cardiac Rationale: Claustrophobia is fear of closed space. D. Resistance is the client’s refusal to submit sedative hypnotic medication that can be used
dysrythmias, peripheral vascular collapse, and A. Agoraphobia is fear of open space or being a himself to the care of the nurse for a limited time because of the risk of
death. situation where escape is difficult. B. Social 75. Answer: (B) Adventitious dependence. Paroxetine is a scrotonin-specific
64. Answer: (C) No acts of aggression have been phobia is fear of performing in the presence of Rationale: Adventitious crisis is a crisis involving reutake inhibitor used for treatment of
observed within 1 hour after the release of two others in a way that will be humiliating or a traumatic event. It is not part of everyday life. depression panic disorder, and obsessive-
of the extremity restraints. embarrassing. D. Xenophobia is fear of A. Situational crisis is from an external source compulsive disorder. Fluoxetine is a scrotonin-
Rationale: The best indicator that the behavior is strangers. that upset ones psychological equilibrium C and specific reuptake inhibitor used for depressive
controlled, if the client exhibits no signs of 71. Answer: (A) Revealing personal information to D. are the same. They are transitional or disorders and obsessive-compulsive disorders.
aggression after partial release of restraints. the client developmental periods in life Risperidome is indicated for psychotic disorders.
Options , B, and D do not ensure that the client Rationale: Counter-transference is an emotional 76. Answer: (C) Major depression 81. Answer: (D) It promotes emotional support or
has controlled the behavior. reaction of the nurse on the client based on her attention for the client
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Rationale: Secondary gain refers to the benefits from moderate depression to hypomania. Clients with antisocial personality disorder can 97. Answer: (B) Echopraxia
of the illness that allow the client to receive Bipolar I disorder is characterized by a single also be antagonistic and argumentative but are Rationale: Echopraxia is the copying of another’s
emotional support or attention. Primary gain manic episode with no past major depressive less suspicious than paranoid personalities. behaviors and is the result of the loss of ego
enables the client to avoid some unpleasant episodes. Seasonal- affective disorder is a form Clients with histrionic personality disorder are boundaries. Modeling is the conscious copying
activity. A dysfunctional family may disregard of depression occurring in the fall and winter. dramatic, not suspicious and argumentative. of someone’s behaviors. Ego-syntonicity refers
the real issue, although some conflict is relieved. 87. Answer: (A) Vascular dementia has more abrupt Clients with schizoid personality disorder are to behaviors that correspond with the
Somatoform pain disorder is a preoccupation onset usually detached from other and tend to have individual’s sense of self. Ritualism behaviors are
with pain in the absence of physical disease. Rationale: Vascular dementia differs from eccentric behavior. repetitive and compulsive.
82. Answer: (A) “I went to the mall with my friends Alzheimer’s disease in that it has a more abrupt 93. Answer: (C) Explain that the drug is less affective 98. Answer: (C) Hallucination
last Saturday” onset and runs a highly variable course. if the client smokes Rationale: Hallucinations are sensory
Rationale: Clients with panic disorder tent to be Personally change is common in Alzheimer’s Rationale: Olanzapine (Zyprexa) is less effective experiences that are misrepresentations of
socially withdrawn. Going to the mall is a sign of disease. The duration of delirium is usually brief. for clients who smoke cigarettes. Serotonin reality or have no basis in reality. Delusions are
working on avoidance behaviors. The inability to carry out motor activities is syndrome occurs with clients who take a beliefs not based in reality. Disorganized speech
Hyperventilating is a key symptom of panic common in Alzheimer’s disease. combination of antidepressant medications. is characterized by jumping from one topic to
disorder. Teaching breathing control is a major 88. Answer: (C) Drug intoxication Olanzapine doesn’t cause euphoria, and the next or using unrelated words. An idea of
intervention for clients with panic disorder. The Rationale: This client was taking several extrapyramidal adverse reactions aren’t a reference is a belief that an unrelated situation
client taking medications for panic disorder; such medications that have a propensity for problem. However, the client should be aware of holds special meaning for the client.
as tricylic antidepressants and benzodiazepines producing delirium; digoxin (a digitalis adverse effects such as tardive dyskinesia. 99. Answer: (C) Regression
must be weaned off these drugs. Most clients glycoxide), furosemide (a thiazide diuretic), and 94. Answer: (A) Lack of honesty Rationale: Regression, a return to earlier
with panic disorder with agoraphobia don’t have diazepam (a benzodiazepine). Sufficient Rationale: Clients with antisocial personality behavior to reduce anxiety, is the basic defense
nutritional problems. supporting data don’t exist to suspect the other disorder tent to engage in acts of dishonesty, mechanism in schizophrenia. Projection is a
83. Answer: (A) “I’m sleeping better and don’t have options as causes. shown by lying. Clients with schizotypal defense mechanism in which one blames others
nightmares” 89. Answer: (D) The client is experiencing visual personality disorder tend to be superstitious. and attempts to justify actions; it’s used
Rationale: MAO inhibitors are used to treat sleep hallucination Clients with histrionic personality disorders tend primarily by people with paranoid schizophrenia
problems, nightmares, and intrusive daytime Rationale: The presence of a sensory stimulus to overreact to frustrations and and delusional disorder. Rationalization is a
thoughts in individual with posttraumatic stress correlates with the definition of a hallucination, disappointments, have temper tantrums, and defense mechanism used to justify one’s action.
disorder. MAO inhibitors aren’t used to help which is a false sensory perception. Aphasia seek attention. Repression is the basic defense mechanism in
control flashbacks or phobias or to decrease the refers to a communication problem. Dysarthria is 95. Answer: (A) “I’m not going to look just at the the neuroses; it’s an involuntary exclusion of
craving for alcohol. difficulty in speech production. Flight of ideas is negative things about myself” painful thoughts, feelings, or experiences from
84. Answer: (D) Stopping the drug can cause rapid shifting from one topic to another. Rationale: As the client makes progress on awareness.
withdrawal symptoms 90. Answer: (D) The client looks at the shadow on a improving self-esteem, self- blame and negative 100. Answer: (A) Should report feelings of
Rationale: Stopping antianxiety drugs such as wall and tells the nurse she sees frightening self-evaluation will decrease. Clients with restlessness or agitation at once
benzodiazepines can cause the client to have faces on the wall. dependent personality disorder tend to feel Rationale: Agitation and restlessness are adverse
withdrawal symptoms. Stopping a Rationale: Minor memory problems are fragile and inadequate and would be extremely effect of haloperidol and can be treated with
benzodiazepine doesn’t tend to cause distinguished from dementia by their minor unlikely to discuss their level of competence and antocholinergic drugs. Haloperidol isn’t likely to
depression, increase cognitive abilities, or severity and their lack of significant interference progress. These clients focus on self and aren’t cause photosensitivity or control essential
decrease sleeping difficulties. with the client’s social or occupational lifestyle. envious or jealous. Individuals with dependent hypertension. Although the client may
85. Answer: (B) Behavioral difficulties Other options would be included in the history personality disorders don’t take over situations experience increased concentration and activity,
Rationale: Adolescents tend to demonstrate data but don’t directly correlate with the client’s because they see themselves as inept and these effects are due to a decreased in
severe irritability and behavioral problems lifestyle. inadequate. symptoms, not the drug itself.
rather than simply a depressed mood. Anxiety 91. Answer: (D) Loose association 96. Answer: (C) Assess for possible physical
disorder is more commonly associated with Rationale: Loose associations are conversations problems such as rash
small children rather than with adolescents. that constantly shift in topic. Concrete thinking Rationale: Clients with schizophrenia generally
Cognitive impairment is typically associated with implies highly definitive thought processes. have poor visceral recognition because they live
delirium or dementia. Labile mood is more Flight of ideas is characterized by conversation so fully in their fantasy world. They need to have
characteristic of a client with cognitive that’s disorganized from the onset. Loose as in-depth assessment of physical complaints
impairment or bipolar disorder. associations don’t necessarily start in a cogently, that may spill over into their delusional
86. Answer: (D) It’s a mood disorder similar to major then becomes loose. symptoms. Talking with the client won’t provide
depression but of mild to moderate severity 92. Answer: (C) Paranoid as assessment of his itching, and itching isn’t as
Rationale: Dysthymic disorder is a mood disorder Rationale: Because of their suspiciousness, adverse reaction of antipsychotic drugs, calling
similar to major depression but it remains mild paranoid personalities ascribe malevolent the physician to get the client’s medication
to moderate in severity. Cyclothymic disorder is activities to others and tent to be defensive, increased doesn’t address his physical
a mood disorder characterized by a mood range becoming quarrelsome and argumentative. complaints.
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PART III PRACTICE TEST I FOUNDATION OF 7. Sterile technique is used whenever: b. Discard all used uncapped needles and b. Before the procedure, the patient should
NURSING a. Strict isolation is required syringes in an impenetrable protective remove all jewelry, metallic objects, and
b. Terminal disinfection is performed container buttons above the waist
1. Which element in the circular chain of infection c. Invasive procedures are performed c. Wear gloves when administering IM c. A signed consent is not required
can be eliminated by preserving skin integrity? d. Protective isolation is necessary injections d. Eating, drinking, and medications are
a. Host d. Follow enteric precautions allowed before this test
b. Reservoir 8. Which of the following constitutes a break in
c. Mode of transmission sterile technique while preparing a sterile field 13. All of the following measures are recommended 19. The most appropriate time for the nurse to
d. Portal of entry for a dressing change? to prevent pressure ulcers except: obtain a sputum specimen for culture is:
a. Using sterile forceps, rather than sterile a. Massaging the reddened are with lotion a. Early in the morning
2. Which of the following will probably result in a gloves, to handle a sterile item b. Using a water or air mattress b. After the patient eats a light breakfast
break in sterile technique for respiratory b. Touching the outside wrapper of c. Adhering to a schedule for positioning c. After aerosol therapy
isolation? sterilized material without sterile gloves and turning d. After chest physiotherapy
a. Opening the patient’s window to the c. Placing a sterile object on the edge of d. Providing meticulous skin care
outside environment the sterile field 20. A patient with no known allergies is to receive
b. Turning on the patient’s room ventilator d. Pouring out a small amount of solution 14. Which of the following blood tests should be penicillin every 6 hours.
c. Opening the door of the patient’s room (15 to 30 ml) before pouring the solution performed before a blood transfusion? 21. When administering the medication, the nurse
leading into the hospital corridor into a sterile container a. Prothrombin and coagulation time observes a fine rash on the patient’s skin. The
d. Failing to wear gloves when 9. A natural body defense that plays an active role b. Blood typing and cross-matching most appropriate nursing action would be to:
administering a bed bath in preventing infection is: c. Bleeding and clotting time a. Withhold the moderation and notify the
a. Yawning d. Complete blood count (CBC) and physician
3. Which of the following patients is at greater risk b. Body hair electrolyte levels. b. Administer the medication and notify
for contracting an infection? c. Hiccupping the physician
a. A patient with leukopenia d. Rapid eye movements 15. The primary purpose of a platelet count is to c. Administer the medication with an
b. A patient receiving broad-spectrum evaluate the: antihistamine
antibiotics 10. All of the following statement are true about a. Potential for clot formation d. Apply corn starch soaks to the rash
c. A postoperative patient who has donning sterile gloves except: b. Potential for bleeding
undergone orthopedic surgery a. The first glove should be picked up by c. Presence of an antigen-antibody 22. All of the following nursing interventions are
d. A newly diagnosed diabetic patient grasping the inside of the cuff. response correct when using the Z- track method of drug
b. The second glove should be picked up by d. Presence of cardiac enzymes injection except:
4. Effective hand washing requires the use of: inserting the gloved fingers under the a. Prepare the injection site with alcohol
a. Soap or detergent to promote cuff outside the glove. 16. Which of the following white blood cell (WBC) b. Use a needle that’s a least 1” long
emulsification c. The gloves should be adjusted by sliding counts clearly indicates leukocytosis? c. Aspirate for blood before injection
b. Hot water to destroy bacteria the gloved fingers under the sterile cuff a. 4,500/mm³ d. Rub the site vigorously after the
c. A disinfectant to increase surface and pulling the glove over the wrist b. 7,000/mm³ injection to promote absorption
tension d. The inside of the glove is considered c. 10,000/mm³
d. All of the above sterile d. 25,000/mm³ 23. The correct method for determining the vastus
lateralis site for I.M. injection is to:
5. After routine patient contact, hand washing 11. When removing a contaminated gown, the nurse 17. After 5 days of diuretic therapy with 20mg of a. Locate the upper aspect of the upper
should last at least: should be careful that the first thing she touches furosemide (Lasix) daily, a patient begins to outer quadrant of the buttock about 5 to
a. 30 seconds is the: exhibit fatigue, muscle cramping and muscle 8 cm below the iliac crest
b. 1 minute a. Waist tie and neck tie at the back of the weakness. These symptoms probably indicate b. Palpate the lower edge of the acromion
c. 2 minute gown that the patient is experiencing: process and the midpoint lateral aspect
d. 3 minutes b. Waist tie in front of the gown a. Hypokalemia of the arm
c. Cuffs of the gown b. Hyperkalemia c. Palpate a 1” circular area anterior to the
6. Which of the following procedures always d. Inside of the gown c. Anorexia umbilicus
requires surgical asepsis? d. Dysphagia d. Divide the area between the greater
a. Vaginal instillation of conjugated 12. Which of the following nursing interventions is femoral trochanter and the lateral
estrogen considered the most effective form or universal 18. Which of the following statements about chest femoral condyle into thirds, and select
b. Urinary catheterization precautions? X-ray is false? the middle third on the anterior of the
c. Nasogastric tube insertion a. Cap all used needles before removing a. No contradictions exist for this test thigh
d. Colostomy irrigation them from their syringes
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24. The mid-deltoid injection site is seldom used for a. Fever d. Order a hemoglobin and hematocrit 43. All of the following are good sources of vitamin A
I.M. injections because it: b. Chronic Obstructive Pulmonary Disease count 1 hour after the arteriography except:
a. Can accommodate only 1 ml or less of c. Renal Failure a. White potatoes
medication d. Dehydration 37. The nurse explains to a patient that a cough: b. Carrots
b. Bruises too easily a. Is a protective response to clear the c. Apricots
c. Can be used only when the patient is 32. All of the following are common signs and respiratory tract of irritants d. Egg yolks
lying down symptoms of phlebitis except: b. Is primarily a voluntary action
d. Does not readily parenteral medication a. Pain or discomfort at the IV insertion site c. Is induced by the administration of an 44. Which of the following is a primary nursing
b. Edema and warmth at the IV insertion antitussive drug intervention necessary for all patients with a
25. The appropriate needle size for insulin injection site d. Can be inhibited by “splinting” the Foley Catheter in place?
is: c. A red streak exiting the IV insertion site abdomen a. Maintain the drainage tubing and
a. 18G, 1 ½” long d. Frank bleeding at the insertion site collection bag level with the patient’s
b. 22G, 1” long 38. An infected patient has chills and begins bladder
c. 22G, 1 ½” long 33. The best way of determining whether a patient shivering. The best nursing intervention is to: b. Irrigate the patient with 1% Neosporin
d. 25G, 5/8” long has learned to instill ear medication properly is a. Apply iced alcohol sponges solution three times a daily
for the nurse to: b. Provide increased cool liquids c. Clamp the catheter for 1 hour every 4
26. The appropriate needle gauge for intradermal a. Ask the patient if he/she has used ear c. Provide additional bedclothes hours to maintain the bladder’s elasticity
injection is: drops before d. Provide increased ventilation d. Maintain the drainage tubing and
a. 20G b. Have the patient repeat the nurse’s collection bag below bladder level to
b. 22G instructions using her own words 39. A clinical nurse specialist is a nurse who has: facilitate drainage by gravity
c. 25G c. Demonstrate the procedure to the a. Been certified by the National League for
d. 26G patient and encourage to ask questions Nursing 45. The ELISA test is used to:
d. Ask the patient to demonstrate the b. Received credentials from the Philippine a. Screen blood donors for antibodies to
27. Parenteral penicillin can be administered as an: procedure Nurses’ Association human immunodeficiency virus (HIV)
a. IM injection or an IV solution c. Graduated from an associate degree b. Test blood to be used for transfusion for
b. IV or an intradermal injection 34. Which of the following types of medications can program and is a registered professional HIV antibodies
c. Intradermal or subcutaneous injection be administered via gastrostomy tube? nurse c. Aid in diagnosing a patient with AIDS
d. IM or a subcutaneous injection a. Any oral medications d. Completed a master’s degree in the d. All of the above
b. Capsules whole contents are dissolve in prescribed clinical area and is a
28. The physician orders gr 10 of aspirin for a water registered professional nurse. 46. The two blood vessels most commonly used for
patient. The equivalent dose in milligrams is: c. Enteric-coated tablets that are TPN infusion are the:
a. 0.6 mg thoroughly dissolved in water 40. The purpose of increasing urine acidity through a. Subclavian and jugular veins
b. 10 mg d. Most tablets designed for oral use, dietary means is to: b. Brachial and subclavian veins
c. 60 mg except for extended-duration a. Decrease burning sensations c. Femoral and subclavian veins
d. 600 mg compounds b. Change the urine’s color d. Brachial and femoral veins
c. Change the urine’s concentration
29. The physician orders an IV solution of dextrose 35. A patient who develops hives after receiving an d. Inhibit the growth of microorganisms 47. Effective skin disinfection before a surgical
5% in water at 100ml/hour. What would the antibiotic is exhibiting drug: procedure includes which of the following
flow rate be if the drop factor is 15 gtt = 1 ml? a. Tolerance 41. Clay colored stools indicate: methods?
a. 5 gtt/minute b. Idiosyncrasy a. Upper GI bleeding a. Shaving the site on the day before
b. 13 gtt/minute c. Synergism b. Impending constipation surgery
c. 25 gtt/minute d. Allergy c. An effect of medication b. Applying a topical antiseptic to the skin
d. 50 gtt/minute d. Bile obstruction on the evening before surgery
36. A patient has returned to his room after femoral c. Having the patient take a tub bath on
30. Which of the following is a sign or symptom of a arteriography. All of the following are 42. In which step of the nursing process would the the morning of surgery
hemolytic reaction to blood transfusion? appropriate nursing interventions except: nurse ask a patient if the medication she d. Having the patient shower with an
a. Hemoglobinuria a. Assess femoral, popliteal, and pedal administered relieved his pain? antiseptic soap on the evening v=before
b. Chest pain pulses every 15 minutes for 2 hours a. Assessment and the morning of surgery
c. Urticaria b. Check the pressure dressing for b. Analysis
d. Distended neck veins sanguineous drainage c. Planning 48. When transferring a patient from a bed to a
c. Assess vital signs every 15 minutes for 2 d. Evaluation chair, the nurse should use which muscles to
31. Which of the following conditions may require hours avoid back injury?
fluid restriction? a. Abdominal muscles
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b. Back muscles ANSWERS AND RATIONALE – FOUNDATION OF to prepare them for reuse by another patient.
c. Leg muscles NURSING The purpose of protective (reverse) isolation is
d. Upper arm muscles to prevent a person with seriously impaired
1. D. In the circular chain of infection, pathogens resistance from coming into contact who
49. Thrombophlebitis typically develops in patients must be able to leave their reservoir and be potentially pathogenic organisms.
with which of the following conditions? transmitted to a susceptible host through a 8. C. The edges of a sterile field are considered
a. Increases partial thromboplastin time portal of entry, such as broken skin. contaminated. When sterile items are allowed to
b. Acute pulsus paradoxus 2. C. Respiratory isolation, like strict isolation, come in contact with the edges of the field, the
c. An impaired or traumatized blood vessel requires that the door to the door patient’s sterile items also become contaminated.
wall room remain closed. However, the patient’s 9. B. Hair on or within body areas, such as the
d. Chronic Obstructive Pulmonary Disease room should be well ventilated, so opening the nose, traps and holds particles that contain
(COPD) window or turning on the ventricular is microorganisms. Yawning and hiccupping do not
desirable. The nurse does not need to wear prevent microorganisms from entering or
50. In a recumbent, immobilized patient, lung gloves for respiratory isolation, but good hand leaving the body. Rapid eye movement marks
ventilation can become altered, leading to such washing is important for all types of isolation. the stage of sleep during which dreaming occurs.
respiratory complications as: 3. A. Leukopenia is a decreased number of 10. D. The inside of the glove is always considered to
a. Respiratory acidosis, ateclectasis, and leukocytes (white blood cells), which are be clean, but not sterile.
hypostatic pneumonia important in resisting infection. None of the 11. A. The back of the gown is considered clean, the
b. Appneustic breathing, atypical other situations would put the patient at risk for front is contaminated. So, after removing gloves
pneumonia and respiratory alkalosis contracting an infection; taking broad- spectrum and washing hands, the nurse should untie the
c. Cheyne-Strokes respirations and antibiotics might actually reduce the infection back of the gown; slowly move backward away
spontaneous pneumothorax risk. from the gown, holding the inside of the gown
d. Kussmail’s respirations and 4. A. Soaps and detergents are used to help and keeping the edges off the floor; turn and
hypoventilation remove bacteria because of their ability to lower fold the gown inside out; discard it in a
the surface tension of water and act as contaminated linen container; then wash her
51. Immobility impairs bladder elimination, resulting emulsifying agents. Hot water may lead to skin hands again.
in such disorders as irritation or burns. 12. B. According to the Centers for Disease Control
a. Increased urine acidity and relaxation of 5. A. Depending on the degree of exposure to (CDC), blood-to-blood contact occurs most
the perineal muscles, causing pathogens, hand washing may last from 10 commonly when a health care worker attempts
incontinence seconds to 4 minutes. After routine patient to cap a used needle. Therefore, used needles
b. Urine retention, bladder distention, and contact, hand washing for 30 seconds effectively should never be recapped; instead they should
infection minimizes the risk of pathogen transmission. be inserted in a specially designed puncture
c. Diuresis, natriuresis, and decreased 6. B. The urinary system is normally free of resistant, labeled container. Wearing gloves is
urine specific gravity microorganisms except at the urinary meatus. not always necessary when administering an I.M.
d. Decreased calcium and phosphate levels Any procedure that involves entering this system injection. Enteric precautions prevent the
in the urine must use surgically aseptic measures to maintain transfer of pathogens via feces.
a bacteria-free state. 13. A. Nurses and other health care professionals
7. C. All invasive procedures, including surgery, previously believed that massaging a reddened
catheter insertion, and administration of area with lotion would promote venous return
parenteral therapy, require sterile technique to and reduce edema to the area. However,
maintain a sterile environment. All equipment research has shown that massage only increases
must be sterile, and the nurse and the physician the likelihood of cellular ischemia and necrosis
must wear sterile gloves and maintain surgical to the area.
asepsis. In the operating room, the nurse and 14. B. Before a blood transfusion is performed, the
physician are required to wear sterile gowns, blood of the donor and recipient must be
gloves, masks, hair covers, and shoe covers for checked for compatibility. This is done by blood
all invasive procedures. Strict isolation requires typing (a test that determines a person’s blood
the use of clean gloves, masks, gowns and type) and cross-matching (a procedure that
equipment to prevent the transmission of highly determines the compatibility of the donor’s and
communicable diseases by contact or by recipient’s blood after the blood types has been
airborne routes. Terminal disinfection is the matched). If the blood specimens are
disinfection of all contaminated supplies and incompatible, hemolysis and antigen-antibody
equipment after a patient has been discharged reactions will occur.
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15. A. Platelets are disk-shaped cells that are 21. D. The Z-track method is an I.M. injection Hemolysis occurs more rapidly in ABO 36. A. Coughing, a protective response that clears
essential for blood coagulation. A platelet count technique in which the patient’s skin is pulled in incompatibilities than in Rh incompatibilities. the respiratory tract of irritants, usually is
determines the number of thrombocytes in such a way that the needle track is sealed off Chest pain and urticarial may be symptoms of involuntary; however it can be voluntary, as
blood available for promoting hemostasis and after the injection. This procedure seals impending anaphylaxis. Distended neck veins are when a patient is taught to perform coughing
assisting with blood coagulation after injury. It medication deep into the muscle, thereby an indication of hypervolemia. exercises. An antitussive drug inhibits coughing.
also is used to evaluate the patient’s potential minimizing skin staining and irritation. Rubbing 30. C. In real failure, the kidney loses their ability to Splinting the abdomen supports the abdominal
for bleeding; however, this is not its primary the injection site is contraindicated because it effectively eliminate wastes and fluids. Because muscles when a patient coughs.
purpose. The normal count ranges from 150,000 may cause the medication to extravasate into of this, limiting the patient’s intake of oral and 37. C. In an infected patient, shivering results from
to 350,000/mm3. A count of 100,000/mm3 or the skin. I.V. fluids may be necessary. Fever, chronic the body’s attempt to increase heat production
less indicates a potential for bleeding; count of 22. D. The vastus lateralis, a long, thick muscle that obstructive pulmonary disease, and dehydration and the production of neutrophils and
less than 20,000/mm3 is associated with extends the full length of the thigh, is viewed by are conditions for which fluids should be phagocytotic action through increased skeletal
spontaneous bleeding. many clinicians as the site of choice for I.M. encouraged. muscle tension and contractions. Initial
16. D. Leukocytosis is any transient increase in the injections because it has relatively few major 31. D. Phlebitis, the inflammation of a vein, can be vasoconstriction may cause skin to feel cold to
number of white blood cells (leukocytes) in the nerves and blood vessels. The middle third of the caused by chemical irritants (I.V. solutions or the touch. Applying additional bed clothes helps
blood. Normal WBC counts range from 5,000 to muscle is recommended as the injection site. medications), mechanical irritants (the needle or to equalize the body temperature and stop the
100,000/mm3. Thus, a count of 25,000/mm3 The patient can be in a supine or sitting position catheter used during venipuncture or chills. Attempts to cool the body result in further
indicates leukocytosis. for an injection into this site. cannulation), or a localized allergic reaction to shivering, increased metabloism, and thus
17. A. Fatigue, muscle cramping, and muscle 23. A. The mid-deltoid injection site can the needle or catheter. Signs and symptoms of increased heat production.
weaknesses are symptoms of hypokalemia (an accommodate only 1 ml or less of medication phlebitis include pain or discomfort, edema and 38. D. A clinical nurse specialist must have
inadequate potassium level), which is a potential because of its size and location (on the deltoid heat at the I.V. insertion site, and a red streak completed a master’s degree in a clinical
side effect of diuretic therapy. The physician muscle of the arm, close to the brachial artery going up the arm or leg from the I.V. insertion specialty and be a registered professional nurse.
usually orders supplemental potassium to and radial nerve). site. The National League of Nursing accredits
prevent hypokalemia in patients receiving 24. D. A 25G, 5/8” needle is the recommended size 32. D. Return demonstration provides the most educational programs in nursing and provides a
diuretics. Anorexia is another symptom of for insulin injection because insulin is certain evidence for evaluating the effectiveness testing service to evaluate student nursing
hypokalemia. Dysphagia means difficulty administered by the subcutaneous route. An of patient teaching. competence but it does not certify nurses. The
swallowing. 18G, 1 ½” needle is usually used for I.M. 33. D. Capsules, enteric-coated tablets, and most American Nurses Association identifies
18. A. Pregnancy or suspected pregnancy is the only injections in children, typically in the vastus extended duration or sustained release products requirements for certification and offers
contraindication for a chest X-ray. However, if a lateralis. A 22G, 1 ½” needle is usually used for should not be dissolved for use in a gastrostomy examinations for certification in many areas of
chest X-ray is necessary, the patient can wear a adult I.M. injections, which are typically tube. They are pharmaceutically manufactured nursing, such as medical surgical nursing. These
lead apron to protect the pelvic region from administered in the vastus lateralis or in these forms for valid reasons, and altering certification (credentialing) demonstrates that
radiation. Jewelry, metallic objects, and buttons ventrogluteal site. them destroys their purpose. The nurse should the nurse has the knowledge and the ability to
would interfere with the X-ray and thus should 25. D. Because an intradermal injection does not seek an alternate physician’s order when an provide high quality nursing care in the area of
not be worn above the waist. A signed consent is penetrate deeply into the skin, a small-bore 25G ordered medication is inappropriate for delivery her certification. A graduate of an associate
not required because a chest X-ray is not an needle is recommended. This type of injection is by tube. degree program is not a clinical nurse specialist:
invasive examination. Eating, drinking and used primarily to administer antigens to 34. D. A drug-allergy is an adverse reaction resulting however, she is prepared to provide bed side
medications are allowed because the X-ray is of evaluate reactions for allergy or sensitivity from an immunologic response following a nursing with a high degree of knowledge and
the chest, not the abdominal region. studies. A 20G needle is usually used for I.M. previous sensitizing exposure to the drug. The skill. She must successfully complete the
19. A. Obtaining a sputum specimen early in this injections of oil- based medications; a 22G reaction can range from a rash or hives to licensing examination to become a registered
morning ensures an adequate supply of bacteria needle for I.M. injections; and a 25G needle, for anaphylactic shock. Tolerance to a drug means professional nurse.
for culturing and decreases the risk of I.M. injections; and a 25G needle, for that the patient experiences a decreasing 39. D. Microorganisms usually do not grow in an
contamination from food or medication. subcutaneous insulin injections. physiologic response to repeated administration acidic environment.
20. A. Initial sensitivity to penicillin is commonly 26. A. Parenteral penicillin can be administered I.M. of the drug in the same dosage. Idiosyncrasy is 40. D. Bile colors the stool brown. Any inflammation
manifested by a skin rash, even in individuals or added to a solution and given I.V. It cannot be an individual’s unique hypersensitivity to a drug, or obstruction that impairs bile flow will affect
who have not been allergic to it previously. administered subcutaneously or intradermally. food, or other substance; it appears to be the stool pigment, yielding light, clay-colored
Because of the danger of anaphylactic shock, he 27. D. gr 10 x 60mg/gr 1 = 600 mg genetically determined. Synergism, is a drug stool. Upper GI bleeding results in black or tarry
nurse should withhold the drug and notify the 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute interaction in which the sum of the drug’s stool. Constipation is characterized by small,
physician, who may choose to substitute 29. A. Hemoglobinuria, the abnormal presence of combined effects is greater than that of their hard masses. Many medications and foods will
another drug. Administering an antihistamine is hemoglobin in the urine, indicates a hemolytic separate effects. discolor stool – for example, drugs containing
a dependent nursing intervention that requires a reaction (incompatibility of the donor’s and 35. D. A hemoglobin and hematocrit count would be iron turn stool black.; beets turn stool red.
written physician’s order. Although applying recipient’s blood). In this reaction, antibodies in ordered by the physician if bleeding were 41. D. In the evaluation step of the nursing process,
corn starch to the rash may relieve discomfort, it the recipient’s plasma combine rapidly with suspected. The other answers are appropriate the nurse must decide whether the patient has
is not the nurse’s top priority in such a donor RBC’s; the cells are hemolyzed in either nursing interventions for a patient who has achieved the expected outcome that was
potentially life-threatening situation. circulatory or reticuloendothelial system. undergone femoral arteriography. identified in the planning phase.
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42. A. The main sources of vitamin A are yellow and not necessarily impede venous return of injure PRACTICE TEST II Maternal and Child Health
green vegetables (such as carrots, sweet vessel walls. 7. The client tells the nurse that her last menstrual
potatoes, squash, spinach, collard greens, 49. A. Because of restricted respiratory movement, a 1. For the client who is using oral contraceptives, period started on January 14 and ended on
broccoli, and cabbage) and yellow fruits (such as recumbent, immobilize patient is at particular the nurse informs the client about the need to January 20. Using Nagele’s rule, the nurse
apricots, and cantaloupe). Animal sources risk for respiratory acidosis from poor gas take the pill at the same time each day to determines her EDD to be which of the
include liver, kidneys, cream, butter, and egg exchange; atelectasis from reduced surfactant accomplish which of the following? following?
yolks. and accumulated mucus in the bronchioles, and a. Decrease the incidence of nausea a. September 27
43. D. Maintaing the drainage tubing and collection hypostatic pneumonia from bacterial growth b. Maintain hormonal levels b. October 21
bag level with the patient’s bladder could result caused by stasis of mucus secretions. c. Reduce side effects c. November 7
in reflux of urine into the kidney. Irrigating the 50. B. The immobilized patient commonly suffers d. Prevent drug interactions d. December 27
bladder with Neosporin and clamping the from urine retention caused by decreased
catheter for 1 hour every 4 hours must be muscle tone in the perineum. This leads to 2. When teaching a client about contraception. 8. When taking an obstetrical history on a pregnant
prescribed by a physician. bladder distention and urine stagnation, which Which of the following would the nurse include client who states, “I had a son born at 38 weeks
44. D. The ELISA test of venous blood is used to provide an excellent medium for bacterial as the most effective method for preventing gestation, a daughter born at 30 weeks gestation
assess blood and potential blood donors to growth leading to infection. Immobility also sexually transmitted infections? and I lost a baby at about 8 weeks,” the nurse
human immunodeficiency virus (HIV). A positive results in more alkaline urine with excessive a. Spermicides should record her obstetrical history as which of
ELISA test combined with various signs and amounts of calcium, sodium and phosphate, a b. Diaphragm the following?
symptoms helps to diagnose acquired gradual decrease in urine production, and an c. Condoms a. G2 T2 P0 A0 L2
immunodeficiency syndrome (AIDS) increased specific gravity. d. Vasectomy b. G3 T1 P1 A0 L2
45. D. Tachypnea (an abnormally rapid rate of c. G3 T2 P0 A0 L2
breathing) would indicate that the patient was 3. When preparing a woman who is 2 days d. G4 T1 P1 A1 L2
still hypoxic (deficient in oxygen).The partial postpartum for discharge, recommendations for
pressures of arterial oxygen and carbon dioxide which of the following contraceptive methods 9. When preparing to listen to the fetal heart rate
listed are within the normal range. Eupnea refers would be avoided? at 12 weeks’ gestation, the nurse would use
to normal respiration. a. Diaphragm which of the following?
46. D. Studies have shown that showering with an b. Female condom a. Stethoscope placed midline at the
antiseptic soap before surgery is the most c. Oral contraceptives umbilicus
effective method of removing microorganisms d. Rhythm method b. Doppler placed midline at the
from the skin. Shaving the site of the intended suprapubic region
surgery might cause breaks in the skin, thereby 4. For which of the following clients would the c. Fetoscope placed midway between the
increasing the risk of infection; however, if nurse expect that an intrauterine device would umbilicus and the xiphoid process
indicated, shaving, should be done immediately not be recommended? d. External electronic fetal monitor placed
before surgery, not the day before. A topical a. Woman over age 35 at the umbilicus
antiseptic would not remove microorganisms b. Nulliparous woman
and would be beneficial only after proper c. Promiscuous young adult 10. When developing a plan of care for a client
cleaning and rinsing. Tub bathing might transfer d. Postpartum client newly diagnosed with gestational diabetes,
organisms to another body site rather than rinse which of the following instructions would be the
them away. 5. A client in her third trimester tells the nurse, priority?
47. C. The leg muscles are the strongest muscles in “I’m constipated all the time!” Which of the a. Dietary intake
the body and should bear the greatest stress following should the nurse recommend? b. Medication
when lifting. Muscles of the abdomen, back, and a. Daily enemas c. Exercise
upper arms may be easily injured. b. Laxatives d. Glucose monitoring
48. C. The factors, known as Virchow’s triad, c. Increased fiber intake
collectively predispose a patient to d. Decreased fluid intake 11. A client at 24 weeks gestation has gained 6
thromboplebitis; impaired venous return to the pounds in 4 weeks. Which of the following would
heart, blood hypercoagulability, and injury to a 6. Which of the following would the nurse use as be the priority when assessing the client?
blood vessel wall. Increased partial the basis for the teaching plan when caring for a a. Glucosuria
thromboplastin time indicates a prolonged pregnant teenager concerned about gaining too b. Depression
bleeding time during fibrin clot formation, much weight during pregnancy? c. Hand/face edema
commonly the result of anticoagulant (heparin) a. 10 pounds per trimester d. Dietary intake
therapy. Arterial blood disorders (such as pulsus b. 1 pound per week for 40 weeks
paradoxus) and lung diseases (such as COPD) do c. ½ pound per week for 40 weeks 12. A client 12 weeks’ pregnant come to the
d. A total gain of 25 to 30 pounds emergency department with abdominal
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cramping and moderate vaginal bleeding. a. A dark red discharge on a 2-day 22. During the first 4 hours after a male b. 3 ounces
Speculum examination reveals 2 to 3 cms postpartum client circumcision, assessing for which of the c. 4 ounces
cervical dilation. The nurse would document b. A pink to brownish discharge on a client following is the priority? d. 6 ounces
these findings as which of the following? who is 5 days postpartum a. Infection
a. Threatened abortion c. Almost colorless to creamy discharge on b. Hemorrhage 27. The postterm neonate with meconium-stained
b. Imminent abortion a client 2 weeks after delivery c. Discomfort amniotic fluid needs care designed to especially
c. Complete abortion d. A bright red discharge 5 days after d. Dehydration monitor for which of the following?
d. Missed abortion delivery a. Respiratory problems
23. The mother asks the nurse. “What’s wrong with b. Gastrointestinal problems
13. Which of the following would be the priority 18. A postpartum client has a temperature of my son’s breasts? Why are they so enlarged?” c. Integumentary problems
nursing diagnosis for a client with an ectopic 101.4ºF, with a uterus that is tender when Whish of the following would be the best d. Elimination problems
pregnancy? palpated, remains unusually large, and not response by the nurse?
a. Risk for infection descending as normally expected. Which of the a. “The breast tissue is inflamed from the 28. When measuring a client’s fundal height, which
b. Pain following should the nurse assess next? trauma experienced with birth” of the following techniques denotes the correct
c. Knowledge Deficit a. Lochia b. “A decrease in material hormones method of measurement used by the nurse?
d. Anticipatory Grieving b. Breasts present before birth causes a. From the xiphoid process to the
c. Incision enlargement,” umbilicus
14. Before assessing the postpartum client’s uterus d. Urine c. “You should discuss this with your b. From the symphysis pubis to the xiphoid
for firmness and position in relation to the doctor. It could be a malignancy” process
umbilicus and midline, which of the following 19. Which of the following is the priority focus of d. “The tissue has hypertrophied while the c. From the symphysis pubis to the fundus
should the nurse do first? nursing practice with the current early baby was in the uterus” d. From the fundus to the umbilicus
a. Assess the vital signs postpartum discharge?
b. Administer analgesia a. Promoting comfort and restoration of 24. Immediately after birth the nurse notes the 29. A client with severe preeclampsia is admitted
c. Ambulate her in the hall health following on a male newborn: respirations 78; with of BP 160/110, proteinuria, and severe
d. Assist her to urinate b. Exploring the emotional status of the apical hearth rate 160 BPM, nostril flaring; mild pitting edema. Which of the following would be
family intercostal retractions; and grunting at the end most important to include in the client’s plan of
15. Which of the following should the nurse do c. Facilitating safe and effective self-and of expiration. Which of the following should the care?
when a primipara who is lactating tells the nurse newborn care nurse do? a. Daily weights
that she has sore nipples? d. Teaching about the importance of family a. Call the assessment data to the b. Seizure precautions
a. Tell her to breast feed more frequently planning physician’s attention c. Right lateral positioning
b. Administer a narcotic before breast b. Start oxygen per nasal cannula at 2 d. Stress reduction
feeding 20. Which of the following actions would be least L/min.
c. Encourage her to wear a nursing effective in maintaining a neutral thermal c. Suction the infant’s mouth and nares 30. A postpartum primipara asks the nurse, “When
brassiere environment for the newborn? d. Recognize this as normal first period of can we have sexual intercourse again?” Which of
d. Use soap and water to clean the nipples a. Placing infant under radiant warmer reactivity the following would be the nurse’s best
after bathing response?
16. The nurse assesses the vital signs of a client, 4 b. Covering the scale with a warmed 25. The nurse hears a mother telling a friend on the a. “Anytime you both want to.”
hours’ postpartum that are as follows: BP 90/60; blanket prior to weighing telephone about umbilical cord care. Which of b. “As soon as choose a contraceptive
temperature 100.4ºF; pulse 100 weak, thready; c. Placing crib close to nursery window for the following statements by the mother method.”
R 20 per minute. Which of the following should family viewing indicates effective teaching? c. “When the discharge has stopped and
the nurse do first? d. Covering the infant’s head with a knit a. “Daily soap and water cleansing is best” the incision is healed.”
a. Report the temperature to the physician stockinette b. ‘Alcohol helps it dry and kills germs” d. “After your 6 weeks examination.”
b. Recheck the blood pressure with c. “An antibiotic ointment applied daily
another cuff 21. A newborn who has an asymmetrical Moro prevents infection” 31. When preparing to administer the vitamin K
c. Assess the uterus for firmness and reflex response should be further assessed for d. “He can have a tub bath each day” injection to a neonate, the nurse would select
position which of the following? which of the following sites as appropriate for
d. Determine the amount of lochia a. Talipes equinovarus 26. A newborn weighing 3000 grams and feeding the injection?
b. Fractured clavicle every 4 hours needs 120 calories/kg of body a. Deltoid muscle
17. The nurse assesses the postpartum vaginal c. Congenital hypothyroidism weight every 24 hours for proper growth and b. Anterior femoris muscle
discharge (lochia) on four clients. Which of the d. Increased intracranial pressure development. How many ounces of 20 cal/oz c. Vastus lateralis muscle
following assessments would warrant formula should this newborn receive at each d. Gluteus maximus muscle
notification of the physician? feeding to meet nutritional needs?
a. 2 ounces
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32. When performing a pelvic examination, the understanding that breathing techniques are d. Partially flexed b. Nurse-midwifery
nurse observes a red swollen area on the right most important in achieving which of the c. Clinical nurse specialist
side of the vaginal orifice. The nurse would following? 42. With a fetus in the left-anterior breech d. Prepared childbirth
document this as enlargement of which of the a. Eliminate pain and give the expectant presentation, the nurse would expect the fetal
following? parents something to do heart rate would be most audible in which of the 48. A client has a midpelvic contracture from a
a. Clitoris b. Reduce the risk of fetal distress by following areas? previous pelvic injury due to a motor vehicle
b. Parotid gland increasing uteroplacental perfusion a. Above the maternal umbilicus and to the accident as a teenager. The nurse is aware that
c. Skene’s gland c. Facilitate relaxation, possibly reducing right of midline this could prevent a fetus from passing through
d. Bartholin’s gland the perception of pain b. In the lower-left maternal abdominal or around which structure during childbirth?
d. Eliminate pain so that less analgesia and quadrant a. Symphysis pubis
33. To differentiate as a female, the hormonal anesthesia are needed c. In the lower-right maternal abdominal b. Sacral promontory
stimulation of the embryo that must occur quadrant c. Ischial spines
involves which of the following? 38. After 4 hours of active labor, the nurse notes d. Above the maternal umbilicus and to the d. Pubic arch
a. Increase in maternal estrogen secretion that the contractions of a primigravida client are left of midline
b. Decrease in maternal androgen not strong enough to dilate the cervix. Which of 49. When teaching a group of adolescents about
secretion the following would the nurse anticipate doing? 43. The amniotic fluid of a client has a greenish tint. variations in the length of the menstrual cycle,
c. Secretion of androgen by the fetal gonad a. Obtaining an order to begin IV oxytocin The nurse interprets this to be the result of the nurse understands that the underlying
d. Secretion of estrogen by the fetal gonad infusion which of the following? mechanism is due to variations in which of the
b. Administering a light sedative to allow a. Lanugo following phases?
34. A client at 8 weeks’ gestation calls complaining the patient to rest for several hour b. Hydramnio a. Menstrual phase
of slight nausea in the morning hours. Which of c. Preparing for a cesarean section for c. Meconium b. Proliferative phase
the following client interventions should the failure to progress d. Vernix c. Secretory phase
nurse question? d. Increasing the encouragement to the d. Ischemic phase
a. Taking 1 teaspoon of bicarbonate of patient when pushing begins 44. A patient is in labor and has just been told she
soda in an 8-ounce glass of water has a breech presentation. The nurse should be 50. When teaching a group of adolescents about
b. Eating a few low-sodium crackers before 39. A multigravida at 38 weeks’ gestation is particularly alert for which of the following? male hormone production, which of the
getting out of bed admitted with painless, bright red bleeding and a. Quickening following would the nurse include as being
c. Avoiding the intake of liquids in the mild contractions every 7 to 10 minutes. Which b. Ophthalmia neonatorum produced by the Leydig cells?
morning hours of the following assessments should be avoided? c. Pica a. Follicle-stimulating hormone
d. Eating six small meals a day instead of a. Maternal vital sign d. Prolapsed umbilical cord b. Testosterone
thee large meals b. Fetal heart rate c. Leuteinizing hormone
c. Contraction monitoring 45. When describing dizygotic twins to a couple, on d. Gonadotropin releasing hormone
35. The nurse documents positive ballottement in d. Cervical dilation which of the following would the nurse base the
the client’s prenatal record. The nurse explanation?
understands that this indicates which of the 40. Which of the following would be the nurse’s a. Two ova fertilized by separate sperm
following? most appropriate response to a client who asks b. Sharing of a common placenta
a. Palpable contractions on the abdomen why she must have a cesarean delivery if she has c. Each ova with the same genotype
b. Passive movement of the unengaged a complete placenta previa? d. Sharing of a common chorion
fetus a. “You will have to ask your physician
c. Fetal kicking felt by the client when he returns.” 46. Which of the following refers to the single cell
d. Enlargement and softening of the uterus b. “You need a cesarean to prevent that reproduces itself after conception?
hemorrhage.” a. Chromosome
36. During a pelvic exam the nurse notes a purple- c. “The placenta is covering most of your b. Blastocyst
blue tinge of the cervix. The nurse documents cervix.” c. Zygote
this as which of the following? d. “The placenta is covering the opening of d. Trophoblast
a. Braxton-Hicks sign the uterus and blocking your baby.”
b. Chadwick’s sign 47. In the late 1950s, consumers and health care
c. Goodell’s sign 41. The nurse understands that the fetal head is in professionals began challenging the routine use
d. McDonald’s sign which of the following positions with a face of analgesics and anesthetics during childbirth.
presentation? Which of the following was an outgrowth of this
37. During a prenatal class, the nurse explains the a. Completely flexed concept?
rationale for breathing techniques during b. Completely extended a. Labor, delivery, recovery, postpartum
preparation for labor based on the c. Partially extended (LDRP)
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ANSWERS AND RATIONALE – MATERNAL AND 4. C. An IUD may increase the risk of pelvic 7 days have been added to the last day of the suspected, which may be caused by fluid
CHILD HEALTH inflammatory disease, especially in women with LMP (rather than the first day of the LMP), plus 4 retention manifested by edema, especially of the
more than one sexual partner, because of the months (instead of 3 months) were counted hands and face. The three classic signs of
1. B. Regular timely ingestion of oral contraceptives increased risk of sexually transmitted infections. back. To obtain the date of November 7, 7 days preeclampsia are hypertension, edema, and
is necessary to maintain hormonal levels of the An UID should not be used if the woman has an have been subtracted (instead of added) from proteinuria. Although urine is checked for
drugs to suppress the action of the active or chronic pelvic infection, postpartum the first day of LMP plus November indicates glucose at each clinic visit, this is not the priority.
hypothalamus and anterior pituitary leading to infection, endometrial hyperplasia or carcinoma, counting back 2 months (instead of 3 months) Depression may cause either anorexia or
inappropriate secretion of FSH and LH. or uterine abnormalities. Age is not a factor in from January. To obtain the date of December excessive food intake, leading to excessive
Therefore, follicles do not mature, ovulation is determining the risks associated with IUD use. 27, 7 days were added to the last day of the LMP weight gain or loss. This is not, however, the
inhibited, and pregnancy is prevented. The Most IUD users are over the age of 30. Although (rather than the first day of the LMP) and priority consideration at this time. Weight gain
estrogen content of the oral site contraceptive there is a slightly higher risk for infertility in December indicates counting back only 1 month thought to be caused by excessive food intake
may cause the nausea, regardless of when the women who have never been pregnant, the IUD (instead of 3 months) from January. would require a 24-hour diet recall. However,
pill is taken. Side effects and drug interactions is an acceptable option as long as the risk- 8. D. The client has been pregnant four times, excessive intake would not be the primary
may occur with oral contraceptives regardless of benefit ratio is discussed. IUDs may be inserted including current pregnancy (G). Birth at 38 consideration for this client at this time.
the time the pill is taken. immediately after delivery, but this is not weeks’ gestation is considered full term (T), 12. B. Cramping and vaginal bleeding coupled with
2. C. Condoms, when used correctly and recommended because of the increased risk and while birth form 20 weeks to 38 weeks is cervical dilation signifies that termination of the
consistently, are the most effective rate of expulsion at this time. considered preterm (P). A spontaneous abortion pregnancy is inevitable and cannot be
contraceptive method or barrier against 5. C. During the third trimester, the enlarging occurred at 8 weeks (A). She has two living prevented. Thus, the nurse would document an
bacterial and viral sexually transmitted uterus places pressure on the intestines. This children (L). imminent abortion. In a threatened abortion,
infections. Although spermicides kill sperm, they coupled with the effect of hormones on smooth 9. B. At 12 weeks gestation, the uterus rises out of cramping and vaginal bleeding are present, but
do not provide reliable protection against the muscle relaxation causes decreased intestinal the pelvis and is palpable above the symphysis there is no cervical dilation. The symptoms may
spread of sexually transmitted infections, motility (peristalsis). Increasing fiber in the diet pubis. The Doppler intensifies the sound of the subside or progress to abortion. In a complete
especially intracellular organisms such as HIV. will help fecal matter pass more quickly through fetal pulse rate so it is audible. The uterus has abortion all the products of conception are
Insertion and removal of the diaphragm along the intestinal tract, thus decreasing the amount merely risen out of the pelvis into the abdominal expelled. A missed abortion is early fetal
with the use of the spermicides may cause of water that is absorbed. As a result, stool is cavity and is not at the level of the umbilicus. intrauterine death without expulsion of the
vaginal irritations, which could place the client at softer and easier to pass. Enemas could The fetal heart rate at this age is not audible products of conception.
risk for infection transmission. Male sterilization precipitate preterm labor and/or electrolyte loss with a stethoscope. The uterus at 12 weeks is 13. B. For the client with an ectopic pregnancy,
eliminates spermatozoa from the ejaculate, but and should be avoided. Laxatives may cause just above the symphysis pubis in the abdominal lower abdominal pain, usually unilateral, is the
it does not eliminate bacterial and/or viral preterm labor by stimulating peristalsis and may cavity, not midway between the umbilicus and primary symptom. Thus, pain is the priority.
microorganisms that can cause sexually interfere with the absorption of nutrients. Use the xiphoid process. At 12 weeks the FHR would Although the potential for infection is always
transmitted infections. for more than 1 week can also lead to laxative be difficult to auscultate with a fetoscope. present, the risk is low in ectopic pregnancy
3. A. The diaphragm must be fitted individually to dependency. Liquid in the diet helps provide a Although the external electronic fetal monitor because pathogenic microorganisms have not
ensure effectiveness. Because of the changes to semisolid, soft consistency to the stool. Eight to would project the FHR, the uterus has not risen been introduced from external sources. The
the reproductive structures during pregnancy ten glasses of fluid per day are essential to to the umbilicus at 12 weeks. client may have a limited knowledge of the
and following delivery, the diaphragm must be maintain hydration and promote stool 10. A. Although all of the choices are important in pathology and treatment of the condition and
refitted, usually at the 6 weeks’ examination evacuation. the management of diabetes, diet therapy is the will most likely experience grieving, but this is
following childbirth or after a weight loss of 15 6. D. To ensure adequate fetal growth and mainstay of the treatment plan and should not the priority at this time.
lbs or more. In addition, for maximum development during the 40 weeks of a always be the priority. Women diagnosed with 14. D. Before uterine assessment is performed, it is
effectiveness, spermicidal jelly should be placed pregnancy, a total weight gain 25 to 30 pounds is gestational diabetes generally need only diet essential that the woman empty her bladder. A
in the dome and around the rim. However, recommended: 1.5 pounds in the first 10 weeks; therapy without medication to control their full bladder will interfere with the accuracy of
spermicidal jelly should not be inserted into the 9 pounds by 30 weeks; and 27.5 pounds by 40 blood sugar levels. Exercise, is important for all the assessment by elevating the uterus and
vagina until involution is completed at weeks. The pregnant woman should gain less pregnant women and especially for diabetic displacing to the side of the midline. Vital sign
approximately 6 weeks. Use of a female condom weight in the first and second trimester than in women, because it burns up glucose, thus assessment is not necessary unless an
protects the reproductive system from the the third. During the first trimester, the client decreasing blood sugar. However, dietary intake, abnormality in uterine assessment is identified.
introduction of semen or spermicides into the should only gain 1.5 pounds in the first 10 not exercise, is the priority. All pregnant women Uterine assessment should not cause acute pain
vagina and may be used after childbirth. Oral weeks, not 1 pound per week. A weight gain of ½ with diabetes should have periodic monitoring that requires administration of analgesia.
contraceptives may be started within the first pound per week would be 20 pounds for the of serum glucose. However, those with Ambulating the client is an essential component
postpartum week to ensure suppression of total pregnancy, less than the recommended gestational diabetes generally do not need daily of postpartum care, but is not necessary prior to
ovulation. For the couple who has determined amount. glucose monitoring. The standard of care assessment of the uterus.
the female’s fertile period, using the rhythm 7. B. To calculate the EDD by Nagele’s rule, add 7 recommends a fasting and 2- hour postprandial 15. A. Feeding more frequently, about every 2
method, avoidance of intercourse during this days to the first day of the last menstrual period blood sugar level every 2 weeks. hours, will decrease the infant’s frantic, vigorous
period, is safe and effective. and count back 3 months, changing the year 11. C. After 20 weeks’ gestation, when there is a sucking from hunger and will decrease breast
appropriately. To obtain a date of September 27, rapid weight gain, preeclampsia should be engorgement, soften the breast, and promote
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ease of correct latching-on for feeding. Narcotics 18. A. The data suggests an infection of the prophylactic dose is often not sufficient to for gastrointestinal problems. Even though the
administered prior to breast feeding are passed endometrial lining of the uterus. The lochia may prevent bleeding. Although infection is a skin is stained with meconium, it is noninfectious
through the breast milk to the infant, causing be decreased or copious, dark brown in possibility, signs will not appear within 4 hours (sterile) and nonirritating. The postterm
excessive sleepiness. Nipple soreness is not appearance, and foul smelling, providing further after the surgical procedure. The primary meconium- stained infant is not at additional risk
severe enough to warrant narcotic analgesia. All evidence of a possible infection. All the client’s discomfort of circumcision occurs during the for bowel or urinary problems.
postpartum clients, especially lactating mothers, data indicate a uterine problem, not a breast surgical procedure, not afterward. Although 28. C. The nurse should use a nonelastic, flexible,
should wear a supportive brassiere with wide problem. Typically, transient fever, usually feedings are withheld prior to the circumcision, paper measuring tape, placing the zero point on
cotton straps. This does not, however, prevent 101ºF, may be present with breast the chances of dehydration are minimal. the superior border of the symphysis pubis and
or reduce nipple soreness. Soaps are drying to engorgement. Symptoms of mastitis include 23. B. The presence of excessive estrogen and stretching the tape across the abdomen at the
the skin of the nipples and should not be used influenza-like manifestations. Localized infection progesterone in the maternal- fetal blood midline to the top of the fundus. The xiphoid and
on the breasts of lactating mothers. Dry nipple of an episiotomy or C-section incision rarely followed by prompt withdrawal at birth umbilicus are not appropriate landmarks to use
skin predisposes to cracks and fissures, which causes systemic symptoms, and uterine precipitates breast engorgement, which will when measuring the height of the fundus
can become sore and painful. involution would not be affected. The client data spontaneously resolve in 4 to 5 days after birth. (McDonald’s measurement).
16. D. A weak, thready pulse elevated to 100 BPM do not include dysuria, frequency, or urgency, The trauma of the birth process does not cause 29. B. Women hospitalized with severe
may indicate impending hemorrhagic shock. An symptoms of urinary tract infections, which inflammation of the newborn’s breast tissue. preeclampsia need decreased CNS stimulation to
increased pulse is a compensatory mechanism of would necessitate assessing the client’s urine. Newborns do not have breast malignancy. This prevent a seizure. Seizure precautions provide
the body in response to decreased fluid volume. 19. C. Because of early postpartum discharge and reply by the nurse would cause the mother to environmental safety should a seizure occur.
Thus, the nurse should check the amount of limited time for teaching, the nurse’s priority is have undue anxiety. Breast tissue does not Because of edema, daily weight is important but
lochia present. Temperatures up to 100.48F in to facilitate the safe and effective care of the hypertrophy in the fetus or newborns. not the priority. Preclampsia causes vasospasm
the first 24 hours after birth are related to the client and newborn. Although promoting 24. D. The first 15 minutes to 1 hour after birth is and therefore can reduce utero-placental
dehydrating effects of labor and are considered comfort and restoration of health, exploring the the first period of reactivity involving respiratory perfusion. The client should be placed on her left
normal. Although rechecking the blood pressure family’s emotional status, and teaching about and circulatory adaptation to extrauterine life. side to maximize blood flow, reduce blood
may be a correct choice of action, it is not the family planning are important in The data given reflect the normal changes during pressure, and promote diuresis. Interventions to
first action that should be implemented in light postpartum/newborn nursing care, they are not this time period. The infant’s assessment data reduce stress and anxiety are very important to
of the other data. The data indicate a potential the priority focus in the limited time presented reflect normal adaptation. Thus, the physician facilitate coping and a sense of control, but
impending hemorrhage. Assessing the uterus for by early post-partum discharge. does not need to be notified and oxygen is not seizure precautions are the priority.
firmness and position in relation to the umbilicus 20. C. Heat loss by radiation occurs when the needed. The data do not indicate the presence 30. C. Cessation of the lochial discharge signifies
and midline is important, but the nurse should infant’s crib is placed too near cold walls or of choking, gagging or coughing, which are signs healing of the endometrium. Risk of hemorrhage
check the extent of vaginal bleeding first. Then it windows. Thus placing the newborn’s crib close of excessive secretions. Suctioning is not and infection are minimal 3 weeks after a
would be appropriate to check the uterus, which to the viewing window would be least effective. necessary. normal vaginal delivery. Telling the client
may be a possible cause of the hemorrhage. Body heat is lost through evaporation during 25. B. Application of 70% isopropyl alcohol to the anytime is inappropriate because this response
17. D. Any bright red vaginal discharge would be bathing. Placing the infant under the radiant cord minimizes microorganisms (germicidal) and does not provide the client with the specific
considered abnormal, but especially 5 days after warmer after bathing will assist the infant to be promotes drying. The cord should be kept dry information she is requesting. Choice of a
delivery, when the lochia is typically pink to rewarmed. Covering the scale with a warmed until it falls off and the stump has healed. contraceptive method is important, but not the
brownish. Lochia rubra, a dark red discharge, is blanket prior to weighing prevents heat loss Antibiotic ointment should only be used to treat specific criteria for safe resumption of sexual
present for 2 to 3 days after delivery. Bright red through conduction. A knit cap prevents heat an infection, not as a prophylaxis. Infants should activity. Culturally, the 6- weeks’ examination
vaginal bleeding at this time suggests late loss from the head a large head, a large body not be submerged in a tub of water until the has been used as the time frame for resuming
postpartum hemorrhage, which occurs after the surface area of the newborn’s body. cord falls off and the stump has completely sexual activity, but it may be resumed earlier.
first 24 hours following delivery and is generally 21. B. A fractured clavicle would prevent the normal healed. 31. C. The middle third of the vastus lateralis is the
caused by retained placental fragments or Moro response of symmetrical sequential 26. B. To determine the amount of formula needed, preferred injection site for vitamin K
bleeding disorders. Lochia rubra is the normal extension and abduction of the arms followed by do the following mathematical calculation. 3 kg x administration because it is free of blood vessels
dark red discharge occurring in the first 2 to 3 flexion and adduction. In talipes equinovarus 120 cal/kg per day = 360 calories/day feeding q 4 and nerves and is large enough to absorb the
days after delivery, containing epithelial cells, (clubfoot) the foot is turned medially, and in hours = 6 feedings per day = 60 calories per medication. The deltoid muscle of a newborn is
erythrocyes, leukocytes and decidua. Lochia plantar flexion, with the heel elevated. The feet feeding: 60 calories per feeding; 60 calories per not large enough for a newborn IM injection.
serosa is a pink to brownish serosanguineous are not involved with the Moro reflex. feeding with formula 20 cal/oz = 3 ounces per Injections into this muscle in a small child might
discharge occurring from 3 to 10 days after Hypothyroiddism has no effect on the primitive feeding. Based on the calculation. 2, 4 or 6 cause damage to the radial nerve. The anterior
delivery that contains decidua, erythrocytes, reflexes. Absence of the Moror reflex is the most ounces are incorrect. femoris muscle is the next safest muscle to use
leukocytes, cervical mucus, and microorganisms. significant single indicator of central nervous 27. A. Intrauterine anoxia may cause relaxation of in a newborn but is not the safest. Because of
Lochia alba is an almost colorless to yellowish system status, but it is not a sign of increased the anal sphincter and emptying of meconium the proximity of the sciatic nerve, the gluteus
discharge occurring from 10 days to 3 weeks intracranial pressure. into the amniotic fluid. At birth some of the maximus muscle should not be until the child
after delivery and containing leukocytes, 22. B. Hemorrhage is a potential risk following any meconium fluid may be aspirated, causing has been walking 2 years.
decidua, epithelial cells, fat, cervical mucus, surgical procedure. Although the infant has been mechanical obstruction or chemical 32. D. Bartholin’s glands are the glands on either
cholesterol crystals, and bacteria. given vitamin K to facilitate clotting, the pneumonitis. The infant is not at increased risk side of the vaginal orifice. The clitoris is female
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erectile tissue found in the perineal area above 39. D. The signs indicate placenta previa and vaginal 47. D. Prepared childbirth was the direct result of
the urethra. The parotid glands are open into the exam to determine cervical dilation would not the 1950’s challenging of the routine use of
mouth. Skene’s glands open into the posterior be done because it could cause hemorrhage. analgesic and anesthetics during childbirth. The
wall of the female urinary meatus. Assessing maternal vital signs can help LDRP was a much later concept and was not a
33. D. The fetal gonad must secrete estrogen for the determine maternal physiologic status. Fetal direct result of the challenging of routine use of
embryo to differentiate as a female. An increase heart rate is important to assess fetal well-being analgesics and anesthetics during childbirth.
in maternal estrogen secretion does not affect and should be done. Monitoring the contractions Roles for nurse midwives and clinical nurse
differentiation of the embryo, and maternal will help evaluate the progress of labor. specialists did not develop from this challenge.
estrogen secretion occurs in every pregnancy. 40. D. A complete placenta previa occurs when the 48. C. The ischial spines are located in the mid-pelvic
Maternal androgen secretion remains the same placenta covers the opening of the uterus, thus region and could be narrowed due to the
as before pregnancy and does not affect blocking the passageway for the baby. This previous pelvic injury. The symphysis pubis,
differentiation. Secretion of androgen by the response explains what a complete previa is and sacral promontory, and pubic arch are not part
fetal gonad would produce a male fetus. the reason the baby cannot come out except by of the mid-pelvis.
34. A. Using bicarbonate would increase the amount cesarean delivery. Telling the client to ask the 49. B. Variations in the length of the menstrual cycle
of sodium ingested, which can cause physician is a poor response and would increase are due to variations in the proliferative phase.
complications. Eating low-sodium crackers the patient’s anxiety. Although a cesarean would The menstrual, secretory and ischemic phases
would be appropriate. Since liquids can increase help to prevent hemorrhage, the statement does do not contribute to this variation.
nausea avoiding them in the morning hours not explain why the hemorrhage could occur. 50. B. Testosterone is produced by the Leyding cells
when nausea is usually the strongest is With a complete previa, the placenta is covering in the seminiferous tubules. Follicle-stimulating
appropriate. Eating six small meals a day would the entire cervix, not just most of it. hormone and leuteinzing hormone are released
keep the stomach full, which often decrease 41. B. With a face presentation, the head is by the anterior pituitary gland. The
nausea. completely extended. With a vertex hypothalamus is responsible for releasing
35. B. Ballottement indicates passive movement of presentation, the head is completely or partially gonadotropin-releasing hormone.
the unengaged fetus. Ballottement is not a flexed. With a brow (forehead) presentation, the
contraction. Fetal kicking felt by the client head would be partially extended.
represents quickening. Enlargement and 42. D. With this presentation, the fetal upper torso
softening of the uterus is known as Piskacek’s and back face the left upper maternal abdominal
sign. wall. The fetal heart rate would be most audible
36. B. Chadwick’s sign refers to the purple-blue tinge above the maternal umbilicus and to the left of
of the cervix. Braxton Hicks contractions are the middle. The other positions would be
painless contractions beginning around the 4th incorrect.
month. Goodell’s sign indicates softening of the 43. C. The greenish tint is due to the presence of
cervix. Flexibility of the uterus against the cervix meconium. Lanugo is the soft, downy hair on the
is known as McDonald’s sign. shoulders and back of the fetus. Hydramnios
37. C. Breathing techniques can raise the pain represents excessive amniotic fluid. Vernix is the
threshold and reduce the perception of pain. white, cheesy substance covering the fetus.
They also promote relaxation. Breathing 44. D. In a breech position, because of the space
techniques do not eliminate pain, but they can between the presenting part and the cervix,
reduce it. Positioning, not breathing, increases prolapse of the umbilical cord is common.
uteroplacental perfusion. Quickening is the woman’s first perception of
38. A. The client’s labor is hypotonic. The nurse fetal movement. Ophthalmia neonatorum
should call the physical and obtain an order for usually results from maternal gonorrhea and is
an infusion of oxytocin, which will assist the conjunctivitis. Pica refers to the oral intake of
uterus to contact more forcefully in an attempt nonfood substances.
to dilate the cervix. Administering light sedative 45. A. Dizygotic (fraternal) twins involve two ova
would be done for hypertonic uterine fertilized by separate sperm. Monozygotic
contractions. Preparing for cesarean section is (identical) twins involve a common placenta,
unnecessary at this time. Oxytocin would same genotype, and common chorion.
increase the uterine contractions and hopefully 46. C. The zygote is the single cell that reproduces
progress labor before a cesarean would be itself after conception. The chromosome is the
necessary. It is too early to anticipate client material that makes up the cell and is gained
pushing with contractions. from each parent. Blastocyst and trophoblast are
later terms for the embryo after zygote.
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MEDICAL SURGICAL NURSING d. Urethral discharge 13. Which of the following represents a significant c. Treating the underlying cause
1. Marco who was diagnosed with brain tumor was risk immediately after surgery for repair of aortic d. Replacing depleted blood products
scheduled for craniotomy. In preventing the 7. A client has undergone with penile implant. aneurysm?
development of cerebral edema after surgery, After 24 hrs of surgery, the client’s scrotum was a. Potential wound infection 20. Which of the following findings is the best
the nurse should expect the use of: edematous and painful. The nurse should: b. Potential ineffective coping indication that fluid replacement for the client
a. Diuretics a. Assist the client with sitz bath c. Potential electrolyte balance with hypovolemic shock is adequate?
b. Antihypertensive b. Apply war soaks in the scrotum d. Potential alteration in renal perfusion a. Urine output greater than 30ml/hr
c. Steroids c. Elevate the scrotum using a soft support b. Respiratory rate of 21 breaths/minute
d. Anticonvulsants d. Prepare for a possible incision and 14. Nurse Josie should instruct the client to eat c. Diastolic blood pressure greater than 90
drainage. which of the following foods to obtain the best mmhg
2. Halfway through the administration of blood, supply of Vitamin B12? d. Systolic blood pressure greater than 110
the female client complains of lumbar pain. After 8. Nurse hazel receives emergency laboratory a. dairy products mmhg
stopping the infusion Nurse Hazel should: results for a client with chest pain and b. vegetables
a. Increase the flow of normal saline immediately informs the physician. An increased c. Grains 21. Which of the following signs and symptoms
b. Assess the pain further myoglobin level suggests which of the following? d. Broccoli would Nurse Maureen include in teaching plan
c. Notify the blood bank a. Liver disease as an early manifestation of laryngeal cancer?
d. Obtain vital signs. b. Myocardial damage 15. Karen has been diagnosed with aplastic anemia. a. Stomatitis
c. Hypertension The nurse monitors for changes in which of the b. Airway obstruction
3. Nurse Maureen knows that the positive d. Cancer following physiologic functions? c. Hoarseness
diagnosis for HIV infection is made based on a. Bowel function d. Dysphagia
which of the following: 9. Nurse Maureen would expect the client with b. Peripheral sensation
a. A history of high risk sexual behaviors. mitral stenosis would demonstrate symptoms c. Bleeding tendencies 22. Karina a client with myasthenia gravis is to
b. Positive ELISA and western blot tests associated with congestion in the: d. Intake and out put receive immunosuppressive therapy. The nurse
c. Identification of an associated a. Right atrium understands that this therapy is effective
opportunistic infection b. Superior vena cava 16. Lydia is scheduled for elective splenectomy. because it:
d. Evidence of extreme weight loss and c. Aorta Before the clients goes to surgery, the nurse in a. Promotes the removal of antibodies that
high fever d. Pulmonary charge final assessment would be: impair the transmission of impulses
a. signed consent b. Stimulates the production of
4. Nurse Maureen is aware that a client who has 10. A client has been diagnosed with hypertension. b. vital signs acetylcholine at the neuromuscular
been diagnosed with chronic renal failure The nurse priority nursing diagnosis would be: c. name band junction.
recognizes an adequate amount of high-biologic- a. Ineffective health maintenance d. empty bladder c. Decreases the production of
value protein when the food the client selected b. Impaired skin integrity autoantibodies that attack the
from the menu was: c. Deficient fluid volume 17. What is the peak age range in acquiring acute acetylcholine receptors.
a. Raw carrots d. Pain lymphocytic leukemia (ALL)? d. Inhibits the breakdown of acetylcholine
b. Apple juice a. 4 to 12 years. at the neuromuscular junction.
c. Whole wheat bread 11. Nurse Hazel teaches the client with angina about b. 20 to 30 years
d. Cottage cheese common expected side effects of nitroglycerin c. 40 to 50 years 23. A female client is receiving IV Mannitol. An
including: d. 60 60 70 years assessment specific to safe administration of the
5. Kenneth who has diagnosed with uremic a. high blood pressure said drug is:
syndrome has the potential to develop b. stomach cramps 18. Marie with acute lymphocytic leukemia suffers a. Vital signs q4h
complications. Which among the following c. headache from nausea and headache. These clinical b. Weighing daily
complications should the nurse anticipates: d. shortness of breath manifestations may indicate all of the following c. Urine output hourly
a. Flapping hand tremors except d. Level of consciousness q4h
b. An elevated hematocrit level 12. The following are lipid abnormalities. Which of a. effects of radiation
c. Hypotension the following is a risk factor for the development b. chemotherapy side effects 24. Patricia a 20 year old college student with
d. Hypokalemia of atherosclerosis and PVD? c. meningeal irritation diabetes mellitus requests additional
a. High levels of low density lipid (LDL) d. gastric distension information about the advantages of using a pen
6. A client is admitted to the hospital with benign cholesterol like insulin delivery devices. The nurse explains
prostatic hyperplasia, the nurse most relevant b. High levels of high density lipid (HDL) 19. A client has been diagnosed with Disseminated that the advantages of these devices over
assessment would be: cholesterol Intravascular Coagulation (DIC). Which of the syringes include:
a. Flank pain radiating in the groin c. Low concentration triglycerides following is contraindicated with the client? a. Accurate dose delivery
b. Distention of the lower abdomen d. Low levels of LDL cholesterol. a. Administering Heparin b. Shorter injection time
c. Perineal edema b. Administering Coumadin
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c. Lower cost with reusable insulin a. “Practice using the mechanical aids that d. A client with U.T.I
cartridges 30. A male client has undergone spinal surgery, the you will need when future disabilities
d. Use of smaller gauge needle. nurse should: arise”. 42. Among the following clients, which among them
a. Observe the client’s bowel movement b. “Follow good health habits to change is high risk for potential hazards from the
25. A male client’s left tibia is fractures in an and voiding patterns the course of the disease”. surgical experience?
automobile accident, and a cast is applied. To b. Log-roll the client to prone position c. “Keep active, use stress reduction a. 67-year-old client
assess for damage to major blood vessels from c. Assess the client’s feet for sensation and strategies, and avoid fatigue. b. 49-year-old client
the fracture tibia, the nurse in charge should circulation d. “You will need to accept the necessity c. 33-year-old client
monitor the client for: d. Encourage client to drink plenty of fluids for a quiet and inactive lifestyle”. d. 15-year-old client
a. Swelling of the left thigh
b. Increased skin temperature of the foot 31. Marina with acute renal failure moves into the 36. The nurse is aware the early indicator of hypoxia 43. Nurse Jon assesses vital signs on a client
c. Prolonged reperfusion of the toes after diuretic phase after one week of therapy. During in the unconscious client is: undergone epidural anesthesia.
blanching this phase the client must be assessed for signs a. Cyanosis 44. Which of the following would the nurse assess
d. Increased blood pressure of developing: b. Increased respirations next?
a. Hypovolemia c. Hypertension a. Headache
26. After a long leg cast is removed, the male client b. renal failure d. Restlessness b. Bladder distension
should: c. metabolic acidosis c. Dizziness
a. Cleanse the leg by scrubbing with a brisk d. hyperkalemia 37. A client is experiencing spinal shock. Nurse d. Ability to move legs
motion Myrna should expect the function of the bladder
b. Put leg through full range of motion 32. Nurse Judith obtains a specimen of clear nasal to be which of the following? 45. Nurse Katrina should anticipate that all of the
twice daily drainage from a client with a head injury. Which a. Normal following drugs may be used in the attempt to
c. Report any discomfort or stiffness to the of the following tests differentiates mucus from b. Atonic control the symptoms of Meniere's disease
physician cerebrospinal fluid (CSF)? c. Spastic except:
d. Elevate the leg when sitting for long a. Protein d. Uncontrolled a. Antiemetics
periods of time. b. Specific gravity b. Diuretics
c. Glucose 38. Which of the following stage the carcinogen is c. Antihistamines
27. While performing a physical assessment of a d. Microorganism irreversible? d. Glucocorticoids
male client with gout of the great toe, a. Progression stage
NurseVivian should assess for additional tophi 33. A 22 year old client suffered from his first tonic- b. Initiation stage 46. Which of the following complications associated
(urate deposits) on the: clonic seizure. Upon awakening the client asks c. Regression stage with tracheostomy tube?
a. Buttocks the nurse, “What caused me to have a seizure? d. Promotion stage a. Increased cardiac output
b. Ears Which of the following would the nurse include b. Acute respiratory distress syndrome
c. Face in the primary cause of tonic-clonic seizures in 39. Among the following components thorough pain (ARDS)
d. Abdomen adults more the 20 years? assessment, which is the most significant? c. Increased blood pressure
a. Electrolyte imbalance a. Effect d. Damage to laryngeal nerves
28. Nurse Katrina would recognize that the b. Head trauma b. Cause
demonstration of crutch walking with tripod gait c. Epilepsy c. Causing factors 47. Nurse Faith should recognize that fluid shift in a
was understood when the client places weight d. Congenital defect d. Intensity client with burn injury results from increase in
on the: the:
a. Palms of the hands and axillary regions 34. What is the priority nursing assessment in the 40. A 65 year old female is experiencing flare up of a. Total volume of circulating whole blood
b. Palms of the hand first 24 hours after admission of the client with pruritus. Which of the client’s action could b. Total volume of intravascular plasma
c. Axillary regions thrombotic CVA? aggravate the cause of flare ups? c. Permeability of capillary walls
d. Feet, which are set apart a. Pupil size and papillary response a. Sleeping in cool and humidified d. Permeability of kidney tubules
b. cholesterol level environment
29. Mang Jose with rheumatoid arthritis states, “the c. Echocardiogram b. Daily baths with fragrant soap 48. An 83-year-old woman has several ecchymotic
only time I am without pain is when I lie in bed d. Bowel sounds c. Using clothes made from 100% cotton areas on her right arm. The bruises are probably
perfectly still”. During the convalescent stage, d. Increasing fluid intake caused by:
the nurse in charge with Mang Jose should 35. Nurse Linda is preparing a client with multiple a. increased capillary fragility and
encourage: sclerosis for discharge from the hospital to 41. Atropine sulfate (Atropine) is contraindicated in permeability
a. Active joint flexion and extension home. Which of the following instruction is most all but one of the following client? b. increased blood supply to the skin
b. Continued immobility until pain subsides appropriate? a. A client with high blood c. self-inflicted injury
c. Range of motion exercises twice daily b. A client with bowel obstruction d. elder abuse
d. Flexion exercises three times daily c. A client with glaucoma
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49. Nurse Anna is aware that early adaptation of ANSWERS AND RATIONALE – MEDICAL SURGICAL 14. A. Good source of vitamin B12 are dairy
client with renal carcinoma is: NURSING products and meats.
a. Nausea and vomiting 15. C. Aplastic anemia decreases the bone marrow
b. flank pain 1. C. Glucocorticoids (steroids) are used for their production of RBC’s, white blood cells, and
c. weight gain anti-inflammatory action, which decreases the platelets. The client is at risk for bruising and
d. intermittent hematuria development of edema. bleeding tendencies.
2. A. The blood must be stopped at once, and then 16. B. An elective procedure is scheduled in advance
50. A male client with tuberculosis asks Nurse Brian normal saline should be infused to keep the line so that all preparations can be completed ahead
how long the chemotherapy must be continued. patent and maintain blood volume. of time. The vital signs are the final check that
Nurse Brian’s accurate reply would be: 3. B. These tests confirm the presence of HIV must be completed before the client leaves the
a. 1 to 3 weeks antibodies that occur in response to the room so that continuity of care and assessment
b. 6 to 12 months presence of the human immunodeficiency virus is provided for.
c. 3 to 5 months (HIV). 17. A. The peak incidence of Acute Lymphocytic
d. 3 years and more 4. D. One cup of cottage cheese contains Leukemia (ALL) is 4 years of age. It is uncommon
approximately 225 calories, 27g of protein, 9g of after 15 years of age.
51. A client has undergone laryngectomy. The fat, 30mg cholesterol, and 6g of carbohydrate. 18. D. Acute Lymphocytic Leukemia (ALL) does not
immediate nursing priority would be: Proteins of high biologic value (HBV) contain cause gastric distention. It does invade the
a. Keep trachea free of secretions optimal levels of amino acids essential for life. central nervous system, and clients experience
b. Monitor for signs of infection 5. A. Elevation of uremic waste products causes headaches and vomiting from meningeal
c. Provide emotional support irritation of the nerves, resulting in flapping irritation.
d. Promote means of communication hand tremors. 19. B. Disseminated Intravascular Coagulation (DIC)
6. B. This indicates that the bladder is distended has not been found to respond to oral
with urine, therefore palpable. anticoagulants such as Coumadin.
7. C. Elevation increases lymphatic drainage, 20. A. Urine output provides the most sensitive
reducing edema and pain. indication of the client’s response to therapy for
8. B. Detection of myoglobin is a diagnostic tool to hypovolemic shock. Urine output should be
determine whether myocardial damage has consistently greater than 30 to 35 mL/hr.
occurred. 21. C. Early warning signs of laryngeal cancer can
9. D. When mitral stenosis is present, the left vary depending on tumor location. Hoarseness
atrium has difficulty emptying its contents into lasting 2 weeks should be evaluated because it is
the left ventricle because there is no valve to one of the most common warning signs.
prevent back ward flow into the pulmonary vein, 22. C. Steroids decrease the body’s immune
the pulmonary circulation is under pressure. response thus decreasing the production of
10. A. Managing hypertension is the priority for the antibodies that attack the acetylcholine
client with hypertension. Clients with receptors at the neuromuscular junction
hypertension frequently do not experience pain, 23. C. The osmotic diuretic mannitol is
deficient volume, or impaired skin integrity. It is contraindicated in the presence of inadequate
the asymptomatic nature of hypertension that renal function or heart failure because it
makes it so difficult to treat. increases the intravascular volume that must be
11. C. Because of its widespread vasodilating effects, filtered and excreted by the kidney.
nitroglycerin often produces side effects such as 24. A. These devices are more accurate because
headache, hypotension and dizziness. they are easily to used and have improved
12. A. An increased in LDL cholesterol concentration adherence in insulin regimens by young people
has been documented at risk factor for the because the medication can be administered
development of atherosclerosis. LDL cholesterol discreetly.
is not broken down into the liver but is 25. C. Damage to blood vessels may decrease the
deposited into the wall of the blood vessels. circulatory perfusion of the toes, this would
13. D. There is a potential alteration in renal indicate the lack of blood supply to the
perfusion manifested by decreased urine output. extremity.
The altered renal perfusion may be related to 26. D. Elevation will help control the edema that
renal artery embolism, prolonged hypotension, usually occurs.
or prolonged aortic cross-clamping during the 27. B. Uric acid has a low solubility, it tends to
surgery. precipitate and form deposits at various sites
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where blood flow is least active, including 43. B. The last area to return sensation is in the PSYCHIATRIC NURSING 7. A 20 year old client was diagnosed with
cartilaginous tissue such as the ears. perineal area, and the nurse in charge should dependent personality disorder. Which behavior
28. B. The palms should bear the client’s weight to monitor the client for distended bladder. 1. Marco approached Nurse Trish asking for advice is not likely to be evidence of ineffective
avoid damage to the nerves in the axilla. 44. D. Glucocorticoids play no significant role in on how to deal with his alcohol addiction. Nurse individual coping?
29. A. Active exercises, alternating extension, disease treatment. Trish should tell the client that the only effective a. Recurrent self-destructive behavior
flexion, abduction, and adduction, mobilize 45. D. Tracheostomy tube has several potential treatment for alcoholism is: b. Avoiding relationship
exudates in the joints relieves stiffness and pain. complications including bleeding, infection and a. Psychotherapy c. Showing interest in solitary activities
30. C. Alteration in sensation and circulation laryngeal nerve damage. b. Alcoholics anonymous (A.A.) d. Inability to make choices and decision
indicates damage to the spinal cord, if these 46. C. In burn, the capillaries and small vessels c. Total abstinence without advise
occurs notify physician immediately. dilate, and cell damage cause the release of a d. Aversion Therapy
31. A. In the diuretic phase fluid retained during the histamine-like substance. The substance causes 8. A male client is diagnosed with schizotypal
oliguric phase is excreted and may reach 3 to 5 the capillary walls to become more permeable 2. Nurse Hazel is caring for a male client who personality disorder. Which signs would this
liters daily, hypovolemia may occur and fluids and significant quantities of fluid are lost. experience false sensory perceptions with no client exhibit during social situation?
should be replaced. 47. A. Aging process involves increased capillary basis in reality. This perception is known as: a. Paranoid thoughts
32. C. The constituents of CSF are similar to those of fragility and permeability. Older adults have a a. Hallucinations b. Emotional affect
blood plasma. An examination for glucose decreased amount of subcutaneous fat and b. Delusions c. Independence need
content is done to determine whether a body cause an increased incidence of bruise like c. Loose associations d. Aggressive behavior
fluid is a mucus or a CSF. A CSF normally contains lesions caused by collection of extravascular d. Neologisms
glucose. blood in loosely structured dermis. 9. Nurse Claire is caring for a client diagnosed with
33. B. Trauma is one of the primary causes of brain 48. D. Intermittent pain is the classic sign of renal 3. Nurse Monet is caring for a female client who bulimia. The most appropriate initial goal for a
damage and seizure activity in adults. Other carcinoma. It is primarily due to capillary erosion has suicidal tendency. When accompanying the client diagnosed with bulimia is?
common causes of seizure activity in adults by the cancerous growth. client to the restroom, Nurse Monet should… a. Encourage to avoid foods
include neoplasms, withdrawal from drugs and 49. B. Tubercle bacillus is a drug resistant organism a. Give her privacy b. Identify anxiety causing situations
alcohol, and vascular disease. and takes a long time to be eradicated. Usually a b. Allow her to urinate c. Eat only three meals a day
34. A. It is crucial to monitor the pupil size and combination of three drugs is used for minimum c. Open the window and allow her to get d. Avoid shopping plenty of groceries
papillary response to indicate changes around of 6 months and at least six months beyond some fresh air
the cranial nerves. culture conversion. d. Observe her 10. Nurse Tony was caring for a 41 year old female
35. C. The nurse most positive approach is to 50. A. Patent airway is the most priority; therefore client. Which behavior by the client indicates
encourage the client with multiple sclerosis to removal of secretions is necessary 4. Nurse Maureen is developing a plan of care for a adult cognitive development?
stay active, use stress reduction techniques and female client with anorexia nervosa. Which a. Generates new levels of awareness
avoid fatigue because it is important to support action should the nurse include in the plan? b. Assumes responsibility for her actions
the immune system while remaining active. a. Provide privacy during meals c. Has maximum ability to solve problems
36. D. Restlessness is an early indicator of hypoxia. b. Set-up a strict eating plan for the client and learn new skills
The nurse should suspect hypoxia in unconscious c. Encourage client to exercise to reduce d. Her perception are based on reality
client who suddenly becomes restless. anxiety
37. B. In spinal shock, the bladder becomes d. Restrict visits with the family 11. A neuromuscular blocking agent is administered
completely atonic and will continue to fill unless to a client before ECT therapy. The Nurse should
the client is catheterized. 5. A client is experiencing anxiety attack. The most carefully observe the client for?
38. A. Progression stage is the change of tumor from appropriate nursing intervention should include? a. Respiratory difficulties
the preneoplastic state or low degree of a. Turning on the television b. Nausea and vomiting
malignancy to a fast growing tumor that cannot b. Leaving the client alone c. Dizziness
be reversed. c. Staying with the client and speaking in d. Seizures
39. D. Intensity is the major indicative of severity of short sentences
pain and it is important for the evaluation of the d. Ask the client to play with other clients 12. A 75 year old client is admitted to the hospital
treatment. with the diagnosis of dementia of the
40. B. The use of fragrant soap is very drying to skin 6. A female client is admitted with a diagnosis of Alzheimer’s type and depression. The symptom
hence causing the pruritus. delusions of GRANDEUR. This diagnosis reflects a that is unrelated to depression would be?
41. C. Atropine sulfate is contraindicated with belief that one is: a. Apathetic response to the environment
glaucoma patients because it increases a. Being Killed b. “I don’t know” answer to questions
intraocular pressure. b. Highly famous and important c. Shallow of labile effect
42. A. A 67 year old client is greater risk because the c. Responsible for evil world d. Neglect of personal hygiene
older adult client is more likely to have a less- d. Connected to client unrelated to oneself
effective immune system.
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13. Nurse Trish is working in a mental health facility; following actions by the nurse would be most b. Restlessness & Irritability my best friend. The nurse recognizes that the
the nurse priority nursing intervention for a important? c. Constipation & steatorrhea client is using the defense mechanism known as?
newly admitted client with bulimia nervosa a. Ask a family member to stay with the d. Vomiting and Diarrhea a. Displacement
would be to? client at home temporarily b. Projection
a. Teach client to measure I & O b. Discuss the meaning of the client’s 24. To establish open and trusting relationship with c. Sublimation
b. Involve client in planning daily meal statement with her a female client who has been hospitalized with d. Denial
c. Observe client during meals c. Request an immediate extension for the severe anxiety, the nurse in charge should?
d. Monitor client continuously client a. Encourage the staff to have frequent 30. When working with a male client suffering
d. Ignore the clients statement because it’s interaction with the client phobia about black cats, Nurse Trish should
14. Nurse Patricia is aware that the major health a sign of manipulation b. Share an activity with the client anticipate that a problem for this client would
complication associated with intractable c. Give client feedback about behavior be?
anorexia nervosa would be? 19. Joey a client with antisocial personality disorder d. Respect client’s need for personal space a. Anxiety when discussing phobia
a. Cardiac dysrhythmias resulting to belches loudly. A staff member asks Joey, “Do b. Anger toward the feared object
cardiac arrest you know why people find you repulsive?” this 25. Nurse Monette recognizes that the focus of c. Denying that the phobia exist
b. Glucose intolerance resulting in statement most likely would elicit which of the environmental (MILIEU) therapy is to: d. Distortion of reality when completing
protracted hypoglycemia following client reaction? a. Manipulate the environment to bring daily routines
c. Endocrine imbalance causing cold a. Depensiveness about positive changes in behavior
amenorrhea b. Embarrassment b. Allow the client’s freedom to determine 31. Linda is pacing the floor and appears extremely
d. Decreased metabolism causing cold c. Shame whether or not they will be involved in anxious. The duty nurse approaches in an
intolerance d. Remorsefulness activities attempt to alleviate Linda’s anxiety. The most
c. Role play life events to meet individual therapeutic question by the nurse would be?
15. Nurse Anna can minimize agitation in a 20. Which of the following approaches would be needs a. Would you like to watch TV?
disturbed client by? most appropriate to use with a client suffering d. Use natural remedies rather than drugs b. Would you like me to talk with you?
a. Increasing stimulation from narcissistic personality disorder when to control behavior c. Are you feeling upset now?
b. limiting unnecessary interaction discrepancies exist between what the client d. Ignore the client
c. increasing appropriate sensory states and what actually exist? 26. Nurse Trish would expect a child with a diagnosis
perception a. Rationalization of reactive attachment disorder to: 32. Nurse Penny is aware that the symptoms that
d. ensuring constant client and staff b. Supportive confrontation a. Have more positive relation with the distinguish post-traumatic stress disorder from
contact c. Limit setting father than the mother other anxiety disorder would be:
d. Consistency b. Cling to mother & cry on separation a. Avoidance of situation & certain
16. A 39 year old mother with obsessive-compulsive c. Be able to develop only superficial activities that resemble the stress
disorder has become immobilized by her 21. Cely is experiencing alcohol withdrawal exhibits relation with the others b. Depression and a blunted affect when
elaborate hand washing and walking rituals. tremors, diaphoresis and hyperactivity. Blood d. Have been physically abuse discussing the traumatic situation
Nurse Trish recognizes that the basis of O.C. pressure is 190/87 mmhg and pulse is 92 bpm. c. Lack of interest in family & others
disorder is often: Which of the medications would the nurse 27. When teaching parents about childhood d. Re-experiencing the trauma in dreams or
a. Problems with being too conscientious expect to administer? depression Nurse Trina should say? flashback
b. Problems with anger and remorse a. Naloxone (Narcan) a. It may appear acting out behavior
c. Feelings of guilt and inadequacy b. Benzlropine (Cogentin) b. Does not respond to conventional 33. Nurse Benjie is communicating with a male client
d. Feeling of unworthiness and c. Lorazepam (Ativan) treatment with substance-induced persisting dementia; the
hopelessness d. Haloperidol (Haldol) c. Is short in duration & resolves easily client cannot remember facts and fills in the
d. Looks almost identical to adult gaps with imaginary information. Nurse Benjie is
17. Mario is complaining to other clients about not 22. Which of the following foods would the nurse depression aware that this is typical of?
being allowed by staff to keep food in his room. Trish eliminate from the diet of a client in a. Flight of ideas
Which of the following interventions would be alcohol withdrawal? 28. Nurse Perry is aware that language development b. Associative looseness
most appropriate? a. Milk in autistic child resembles: c. Confabulation
a. Allowing a snack to be kept in his room b. Orange Juice a. Scanning speech d. Concretism
b. Reprimanding the client c. Soda b. Speech lag
c. Ignoring the clients behavior d. Regular Coffee c. Shuttering 34. Nurse Joey is aware that the signs & symptoms
d. Setting limits on the behavior d. Echolalia that would be most specific for diagnosis
23. Which of the following would Nurse Hazel anorexia are?
18. Conney with borderline personality disorder who expect to assess for a client who is exhibiting 29. A 60 year old female client who lives alone tells a. Excessive weight loss, amenorrhea &
is to be discharge soon threatens to “do late signs of heroin withdrawal? the nurse at the community health center “I abdominal distension
something” to herself if discharged. Which of the a. Yawning & diaphoresis really don’t need anyone to talk to”. The TV is b. Slow pulse, 10% weight loss & alopecia
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c. Compulsive behavior, excessive fears & detailed assessment, a diagnosis of 45. Nurse Tina is caring for a client with delirium and 49. Nurse Tina is caring for a client with depression
nausea schizophrenia is made. It is unlikely that the states that “look at the spiders on the wall”. who has not responded to antidepressant
d. Excessive activity, memory lapses & an client will demonstrate: What should the nurse respond to the client? medication. The nurse anticipates that what
increased pulse a. Low self esteem a. “You’re having hallucination, there are treatment procedure may be prescribed.
b. Concrete thinking no spiders in this room at all” a. Neuroleptic medication
35. A characteristic that would suggest to Nurse c. Effective self-boundaries b. “I can see the spiders on the wall, but b. Short term seclusion
Anne that an adolescent may have bulimia d. Weak ego they are not going to hurt you” c. Psychosurgery
would be: c. “Would you like me to kill the spiders” d. Electroconvulsive therapy
a. Frequent regurgitation & re-swallowing 41. A 23 year old client has been admitted with a d. “I know you are frightened, but I do not
of food diagnosis of schizophrenia says to the nurse see spiders on the wall” 50. Mario is admitted to the emergency room with
b. Previous history of gastritis “Yes, its march, March is little woman”. That’s drug-included anxiety related to over ingestion
c. Badly stained teeth literal you know”. These statement illustrate: 46. Nurse Jonel is providing information to a of prescribed antipsychotic medication. The
d. Positive body image a. Neologisms community group about violence in the family. most important piece of information the nurse
b. Echolalia Which statement by a group member would in charge should obtain initially is the:
36. Nurse Monette is aware that extremely c. Flight of ideas indicate a need to provide additional a. Length of time on the med.
depressed clients seem to do best in settings d. Loosening of association information? b. Name of the ingested medication & the
where they have: a. “Abuse occurs more in low-income amount ingested
a. Multiple stimuli 42. A long term goal for a paranoid male client who families” c. Reason for the suicide attempt
b. Routine Activities has unjustifiably accused his wife of having many b. “Abuser Are often jealous or self- d. Name of the nearest relative & their
c. Minimal decision making extramarital affairs would be to help the client centered” phone number
d. Varied Activities develop: c. “Abuser use fear and intimidation”
a. Insight into his behavior d. “Abuser usually have poor self-esteem”
37. To further assess a client’s suicidal potential. b. Better self-control
Nurse Katrina should be especially alert to the c. Feeling of self-worth 47. During electroconvulsive therapy (ECT) the client
client expression of: d. Faith in his wife receives oxygen by mask via positive pressure
a. Frustration & fear of death ventilation. The nurse assisting with this
b. Anger & resentment 43. A male client who is experiencing disordered procedure knows that positive pressure
c. Anxiety & loneliness thinking about food being poisoned is admitted ventilation is necessary because?
d. Helplessness & hopelessness to the mental health unit. The nurse uses which a. Anesthesia is administered during the
communication technique to encourage the procedure
38. A nursing care plan for a male client with bipolar client to eat dinner? b. Decrease oxygen to the brain increases
I disorder should include: a. Focusing on self-disclosure of own food confusion and disorientation
a. Providing a structured environment preference c. Grand mal seizure activity depresses
b. Designing activities that will require the b. Using open ended question and silence respirations
client to maintain contact with reality c. Offering opinion about the need to eat d. Muscle relaxations given to prevent
c. Engaging the client in conversing about d. Verbalizing reasons that the client may injury during seizure activity depress
current affairs not choose to eat respirations.
d. Touching the client provide assurance
44. Nurse Nina is assigned to care for a client 48. When planning the discharge of a client with
39. When planning care for a female client using diagnosed with Catatonic Stupor. When Nurse chronic anxiety, Nurse Chris evaluates
ritualistic behavior, Nurse Gina must recognize Nina enters the client’s room, the client is found achievement of the discharge maintenance
that the ritual: lying on the bed with a body pulled into a fetal goals. Which goal would be most appropriately
a. Helps the client focus on the inability to position. Nurse Nina should? having been included in the plan of care
deal with reality a. Ask the client direct questions to requiring evaluation?
b. Helps the client control the anxiety encourage talking a. The client eliminates all anxiety from
c. Is under the client’s conscious control b. Rake the client into the dayroom to be daily situations
d. Is used by the client primarily for with other clients b. The client ignores feelings of anxiety
secondary gains c. Sit beside the client in silence and c. The client identifies anxiety producing
occasionally ask open-ended question situations
40. A 32 year old male graduate student, who has d. Leave the client alone and continue with d. The client maintains contact with a crisis
become increasingly withdrawn and neglectful providing care to the other clients counselor
of his work and personal hygiene, is brought to
the psychiatric hospital by his parents. After
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ANSWERS AND RATIONALE – PSYCHIATRIC Rationale: With depression, there is little or no Rationale: Regular coffee contains caffeine Rationale: These are the major signs of anorexia
NURSING emotional involvement therefore little alteration which acts as psychomotor stimulants and leads nervosa. Weight loss is excessive (15% of
in affect. to feelings of anxiety and agitation. Serving expected weight)
1. Answer: C 13. Answer: D coffee top the client may add to tremors or 35. Answer: C
Rationale: Total abstinence is the only effective Rationale: These clients often hide food or force wakefulness. Rationale: Dental enamel erosion occurs from
treatment for alcoholism vomiting; therefore they must be carefully 23. Answer: D repeated self-induced vomiting.
2. Answer: A monitored. Rationale: Vomiting and diarrhea are usually the 36. Answer: B
Rationale: Hallucinations are visual, auditory, 14. Answer: A late signs of heroin withdrawal, along with Rationale: Depression usually is both emotional
gustatory, tactile or olfactory perceptions that Rationale: These clients have severely depleted muscle spasm, fever, nausea, repetitive, & physical. A simple daily routine is the best,
have no basis in reality. levels of sodium and potassium because of their abdominal cramps and backache. least stressful and least anxiety producing.
3. Answer: D starvation diet and energy expenditure, these 24. Answer: D 37. Answer: D
Rationale: The Nurse has a responsibility to electrolytes are necessary for cardiac Rationale: Moving to a client’s personal space Rationale: The expression of these feeling may
observe continuously the acutely suicidal client. functioning. increases the feeling of threat, which increases indicate that this client is unable to continue the
The Nurse should watch for clues, such as 15. Answer: B anxiety. struggle of life.
communicating suicidal thoughts, and messages; Rationale: Limiting unnecessary interaction will 25. Answer: A 38. Answer: A
hoarding medications and talking about death. decrease stimulation and agitation. Rationale: Environmental (MILIEU) therapy aims Rationale: Structure tends to decrease agitation
4. Answer: B 16. Answer: C at having everything in the client’s surrounding and anxiety and to increase the client’s feeling of
Rationale: Establishing a consistent eating plan Rationale: Ritualistic behavior seen in this area toward helping the client. security.
and monitoring client’s weight are important to disorder is aimed at controlling guilt and 26. Answer: C 39. Answer: B
this disorder. inadequacy by maintaining an absolute set Rationale: Children who have experienced Rationale: The rituals used by a client with
5. Answer: C pattern of behavior. attachment difficulties with primary caregiver obsessive compulsive disorder help control the
Rationale: Appropriate nursing interventions for 17. Answer: D are not able to trust others and therefore relate anxiety level by maintaining a set pattern of
an anxiety attack include using short sentences, Rationale: The nurse needs to set limits in the superficially action.
staying with the client, decreasing stimuli, client’s manipulative behavior to help the client 27. Answer: A 40. Answer: C
remaining calm and medicating as needed. control dysfunctional behavior. A consistent Rationale: Children have difficulty verbally Rationale: A person with this disorder would not
6. Answer:B approach by the staff is necessary to decrease expressing their feelings, acting out behavior, have adequate self-boundaries
Rationale: Delusion of grandeur is a false belief manipulation. such as temper tantrums, may indicate 41. Answer: D
that one is highly famous and important. 18. Answer: B underlying depression. Rationale: Loose associations are thoughts that
7. Answer: D Rationale: Any suicidal statement must be 28. Answer: D are presented without the logical connections
Rationale: Individual with dependent personality assessed by the nurse. The nurse should discuss Rationale: The autistic child repeats sounds or usually necessary for the listening to interpret
disorder typically shows indecisiveness the client’s statement with her to determine its words spoken by others. the message.
submissiveness and clinging behavior so that meaning in terms of suicide. 29. Answer: D 42. Answer: C
others will make decisions with them. 19. Answer: A Rationale: The client statement is an example of Rationale: Helping the client to develop feeling
8. Answer: A Rationale: When the staff member ask the client the use of denial, a defense that blocks problem of self-worth would reduce the client’s need to
Rationale: Clients with schizotypal personality if he wonders why others find him repulsive, the by unconscious refusing to admit they exist use pathologic defenses.
disorder experience excessive social anxiety that client is likely to feel defensive because the 30. Answer: A 43. Answer: B
can lead to paranoid thoughts question is belittling. The natural tendency is to Rationale: Discussion of the feared object Rationale: Open ended questions and silence are
9. Answer: B counterattack the threat to self-image. triggers an emotional response to the object. strategies used to encourage clients to discuss
Rationale: Bulimia disorder generally is a 20. Answer: B 31. Answer: B their problem in descriptive manner.
maladaptive coping response to stress and Rationale: The nurse would specifically use Rationale: The nurse presence may provide the 44. Answer: C
underlying issues. The client should identify supportive confrontation with the client to point client with support & feeling of control. Rationale: Clients who are withdrawn may be
anxiety causing situation that stimulate the out discrepancies between what the client states 32. Answer: D immobile and mute, and require consistent,
bulimic behavior and then learn new ways of and what actually exists to increase Rationale: Experiencing the actual trauma in repeated interventions. Communication with
coping with the anxiety. responsibility for self. dreams or flashback is the major symptom that withdrawn clients requires much patience from
10. Answer: A 21. Answer: C distinguishes post-traumatic stress disorder from the nurse. The nurse facilitates communication
Rationale: An adult age 31 to 45 generates new Rationale: The nurse would most likely other anxiety disorder. with the client by sitting in silence, asking open-
level of awareness. administer benzodiazepine, such as lorazepan 33. Answer: C ended question and pausing to provide
11. Answer: A (ativan) to the client who is experiencing Rationale: Confabulation or the filling in of opportunities for the client to respond.
Rationale: Neuromuscular Blocker, such as symptom: The client’s experiences symptoms of memory gaps with imaginary facts is a defense 45. Answer: D
SUCCINYLCHOLINE (Anectine) produces withdrawal because of the rebound mechanism used by people experiencing Rationale: When hallucination is present, the
respiratory depression because it inhibits phenomenon when the sedation of the CNS memory deficits. nurse should reinforce reality with the client.
contractions of respiratory muscles. from alcohol begins to decrease. 34. Answer: A 46. Answer: A
12. Answer: C 22. Answer: D
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Rationale: Personal characteristics of abuser FOUNDATION OF PROFESSIONAL NURSING a. There are many alternative sites for subcutaneous
include low self-esteem, immaturity, PRACTICE injection
dependence, insecurity and jealousy. b. Absorption time of the medicine is slower
47. Answer: D Situation 1 - Mr. Ibarra is assigned to the triage area and c. There are less pain receptors in this area
Rationale: A short acting skeletal muscle relaxant while on duty, he assesses the condition of Mrs. Simon d. The medication can be injected while the client is in
such as succinylcholine (Anectine) is who came in with asthma. She has difficulty breathing any position
administered during this procedure to prevent and her respiratory rate is 40 per minute. Mr. Ibarra is
injuries during seizure. asked to inject the client epinephrine 0.3mg Situation 2 - The use of massage and meditation to help
48. Answer: C subcutaneously decrease stress and pain have been strongly
Rationale: Recognizing situations that produce recommended based on documented testimonials.
anxiety allows the client to prepare to cope with 1. The indication for epinephrine injection for Mrs
anxiety or avoid specific stimulus. Simon is to: 6. Martha wants to do a study on, this topic. "Effects of
49. Answer: D massage and meditation on stress and pain." The type
Rationale: Electroconvulsive therapy is an a. Reduce anaphylaxis of research that best suits this topic is:
effective treatment for depression that has not b. Relieve hypersensitivity to allergen
responded to medication c. Relieve respirator distress due to bronchial spasm a. applied research
50. Answer: B d. Restore client’s cardiac rhythm b. qualitative research
Rationale: In an emergency, lives saving facts are c. basic research
obtained first. The name and the amount of 2. When preparing the epinephrine injection from an d. quantitative research
medication ingested are of outmost important in ampule, the nurse initially:
treating this potentially life threatening 7. The type of research design that does not manipulate
situation. a. Taps the ampule at the top to allow fluid to flow to independent variable is:
the base of the ampule
b. Checks expiration date of the medication ampule a. experimental design
c. Removes needle cap of syringe and pulls plunger to b. quasi-experimental design
expel air c. non-experimental design
d. Breaks the neck of the ampule with a gauze wrapped d. quantitative design
around it
8. This research topic has the potential to contribute to
3. Mrs. Simon is obese. When administering a nursing because it seeks to:
subcutaneous injection to an obese patient, it is best
for the nurse to: a. include new modalities of care
b. resolve a clinical problem
a Inject needle at a 15 degree angle' over the stretched c. clarify an ambiguous modality of care
skin of the client d. enhance client care
b. Pinch skin at the Injection site and use airlock
technique 9. Martha does review of related literature for the
c. Pull skin of patient down to administer the drug in a Z purpose of:
track
d. Spread skin or pinch at the injection site and inject a. determine statistical treatment of data research
needle at a 45-90 degree angle b. gathering data about what is already known or
unknown
4. When preparing for a subcutaneous injection, the c. to identify if problem can be replicated
proper size of syringe and needle would be: d. answering the research question
a. Syringe 3-5ml and needle gauge 21 to 23 10. Client’s rights should be protected when doing
b. Tuberculin syringe 1 mi with needle gauge 26 or 27 research using human subjects. Martha identifies these
c. Syringe 2ml and needle gauge 22 rights as follows EXCEPT:
d. Syringe 1-3ml and needle gauge 25 to 27
a. right of self-determination
5. The rationale for giving medications through the b. right to compensation
subcutaneous route is; c. right of privacy
d. right not to be harmed
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c. Client has no signs of infection waking up 23. The nurse visits Nancy and prods her to eat her
Situation 3 - Richard has a nursing diagnosis of d. Time of fast food and fluid intake of the client food. Nancy replies "what's the use? My time is running
ineffective airway clearance related to excessive 19. Mr. Regalado's lower extremities are swollen and out. The nurse's best response would be:
secretions and is at risk for infection because of retained 15. The purpose of chest percussion and vibration is to shiny. He has pitting pedal edema. When taking care of
secretions. Part of Nurse Mario's nursing care plan is to loosen secretions in the lungs. The difference between Mr. Regalado, which of the following intervention a. "The doctor ordered full diet for you so that you will
loosen and remove excessive secretions in the airway, the procedure is; would be the most appropriate immediate nursing be strong for surgery."
approach. b. "I understand how you fee! but you have 1o try for
11. Mario listens to Richard's bilateral sounds and finds a. Percussion uses only one hand white vibration uses your children's sake."
that congestion is in the upper lobes of the lungs. The both hands a. Moisturize lower extremities to prevent skin irritation c. "Have you told your, doctor how you feel? Are you
appropriate position to drain the anterior and posterior b. Percussion delivers cushioned blows to the chest with b. Measure fluid intake and output to decrease edema changing your mind) about surgery?"
apical segments of the lungs when Mario does cupped palms while gently shakes secretion loose on the c. Elevate lower extremities for postural drainage d. "You sound like you are giving up."
percussion would be: exhalation cycle d. Provide the client a list of food low in sodium
c. In both percussion and vibration the hands are on top 24. The nurse feels sad about Nancy's illness and tells
a. Client lying on his back then flat on his abdomen on of each other and hand action is in tune with client's 20. Mr. Regalado will be discharged from your unit her head nurse during the end of shift endorsement
Trendelenburg position breath rhythm within the hour. Nursing actions when preparing a that "it's unfair for Nancy to have cancer when she is
b. Client seated upright in bed or on a chair then leaning d. Percussion slaps the chest to loosen secretions while client for discharge include all EXCEPT: still so young and with two kinds. The best response of
forward in sitting position then flat on his back and on vibration shakes the secretions along with the inhalation the head nurse would be:
his abdomen of air a. Making a final physical assessment before client
c. Client lying flat on his back and then flat on his leaves the hospital a. Advise the nurse to "be strong and learn to control her
abdomen Situation 4 - A 61 year old man, Mr. Regalado, is b. Giving instructions about his medication regimen feelings"
d. Client lying on his right then left side on admitted to the private ward for observation; after c. Walking the client to the hospital exit to ensure his b. Assign the nurse to another client to avoid sympathy
Trendelenburg position complaints of severe chest pain. You are assigned to take safety for the client
care of the client. d. Proper recording of pertinent data c. Reassure the nurse that the client has hope if she goes
12. When documenting outcome of Richard's treatment through all statements prescribed for her
Mario should include the following in his recording 16. When doing an initial assessment, the best way for Situation 5 - Nancy, mother of 2 young kids. 36 years old, c. Ask the other nurses what they feel about the patient
EXCEPT: you to identify the client’s priority problem is to: had a mammogram and was told that she has breast to find out if they share the same feelings
cysts and that she may need surgery. This causes her
a. Color, amount and consistent of sputum a. Interview the client for chief complaints and other anxiety as shown by increase in her pulse and respiratory 25. Realizing that she feels angry about Nancy's
b. Character of breath sounds and respirator/rate before symptoms rate, sweating and feelings of tension. condition, the nurse Seams that being self-aware is a
and after procedure b. Talk to the relatives to gather data about history of conscious process that she should do in any situation
c. Amount of fluid intake of client before and after the illness 21. Considering her level of anxiety, the nurse can best like this because:
procedure c. Do auscultation to check for chest congestion assist Nancy by:
d. Significant changes in vital signs d. Do a physical examination white asking the client a. This is a necessary part of the nurse -client
relevant questions a. Giving her activities to divert her attention relationship process
13. When assessing Richard for chest percussion or b. Giving detailed explanations about the treatments she b. The nurse is a role model for the client and should be
chest vibration and postural drainage Mario would 17. Upon establishing Mr. Regalado's nursing needs, will undergo strong
focus on the following EXCEPT: the next nursing approach would be to: c. Preparing her and her family in case surgery is not C. How the nurse thinks and feels affect her actions
successful towards her client and her work
a. Amount of food and fluid taken during the last meal a. introduce the client to the ward staff to put the client d. Giving her clear but brief information at the level of d. The nurse has to be therapeutic at all times and
before treatment and family at ease her understanding should not be affected
b. Respiratory rate, breath sounds and location of b. Give client and relatives a brief tour of the physical set
congestion up the unit 22. Nancy blames God for her situation. She is easily Situation 6 – Mrs. Seva, 32 years old, asks you about
c. Teaching the client's relatives to perform 'the c. Take his vital signs for a baseline assessment provoked to tears and wants to be left alone, refusing possible problems regarding her elimination now that
procedure d. Establish priority needs and implement appropriate to eat or talk to her family. A religious person before, she is in the menopausal stage.
d. Doctor's order regarding position restriction and interventions she now refuses to pray or go to church stating that
client's tolerance for lying flat God has abandoned her. The nurse understands that 26. Instruction on health promotion regarding urinary
18. Mr. Regalado says he has "trouble going to sleep". Nancy is grieving for her self and is in the stage of: elimination is important. Which would you include?
14. Mario prepares Richard for postural drainage and In order to plan your nursing intervention you will.
percussion. Which of the flowing is a special a. bargaining a. Hold urine, as long as she can before emptying the
consideration when doing the procedure? a. Observe his sleeping patterns in the next few days b. denial bladder to strengthen her sphincters muscles
b. Ask him what he means by this statement c. anger b. If burning sensation is experienced while voiding,
a. Respiratory rate of 16 to 20 per minute c. Check his physical environment to decrease noise level d. acceptance drink pineapple-juice
b. Client can tolerate sitting and lying position d. Take his blood pressure before sleeping and upon c. After urination, wipe from anal area up towards the
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pubis
d. Jell client to empty the bladder at each voiding a. Carol with a tumor in the brain a. deflated fully then immediately start second reading a. Assess damage to property
b. Theresa with anemia for same client b. Assist in the police investigation since she is a witness
27. Mrs. Seva also tells the nurse that she is often c. Sonny Boy with a fracture in the femur b deflated quickly after inflating up to 180 mmHg c. Report the incident immediately to the local police
constipated. Because she is aging, what physical d. Brigette with diarrhea c. large enough to wrap around upper arm of the adult authorities
changes predispose her to constipation? client 1 cm above brachial artery d. Assess the extent of injuries incurred by the victims, of
32. You noted from the lab exams in the chart of Mr. d. inflated to 30 mmHg above the estimated systolic BP the accident
a. inhibition of the parasympathetic reflex Santos that he has reduced oxygen in the blood. based on palpation of radial or bronchial artery
b. weakness of sphincter muscles of the anus This condition is called: 42. Priority attention should be given to which of these
c. loss of tone of the smooth muscles of the color 37. Chronic Obstructive Pulmonary Disease (COPD) in clients?
d. decreased ability to absorb fluids in the lower a. Cyanosis one of the leading causes of death worldwide and is a
intestines b. Hypoxia preventable disease. The primary cause of COPD is: a. Linda who shows severe anxiety due to trauma of the
c. Hypoxemia accident
28. The nurse understands that one of these factors d. Anemia a. tobacco hack b. Ryan who has chest injury, is pate and with difficulty
contributes to constipation: b. bronchitis of breathing
33. You will nasopharyngeal suctioning Mr. Abad. Your c. asthma c. Noel who has lacerations on the arms with mild-
a. excessive exercise guide for the length of insertion of the tubing for an d. cigarette smoking bleeding
b. high fiber diet adult would be: c. Andy whose left ankle swelled and has some abrasions
c. no regular tine for defecation daily 38. In your health education class for clients with
d. prolonged use of laxatives a. tip of the nose to the base of the .neck diabetes you teach, them the areas, for control . 43. In the emergency room, Nurse Rivera is assigned to
b. the distance from the tip of the nose to the middle of Diabetes which include all EXCEPT: attend to the client with .lacerations on the arms, while
29. Mrs. Seva talks about rear of being incontinent due the cheek assessing the extent of the wound the nurse observes
to a prior experience of dribbling urine when laughing c. the distance from the tip of the nose to the tip of the a. regular physical activity that the wound is now starting to bleed profusely. The
or sneezing and when she has a full bladder. Your most ear lobe b. thorough knowledge of foot care most immediate nursing action would be to:
appropriate .instruction would be to: d. eight to ten inches c. prevention nutrition
d. proper nutrition a. Apply antiseptic to prevent infection
a. tell client to drink less fluids to avoid accidents 34. While doing nasopharyngeal suctioning on .Mr. b. Clean the wound vigorously of contaminants
b. instruct client to start wearing thin adult diapers Abad, the nurse can avoid trauma to the area by: 39. You teach your clients the difference between, Type c. Control and. reduce bleeding of the wound
c. ask the client to bring change of underwear "just in I (IDDM) and Type II (NDDM) Diabetes. Which of the d. Bandage the wound and elevate the arm
case" a. Apply suction for at least 20-30 seconds each time to following is true?
d. teach client pelvic exercise to strengthen perineal ensure that all secretions are removed 44. The nurse applies pressure dressing on the bleeding
muscles b. Using gloves to prevent introduction of pathogens to a. both types diabetes mellitus clients are all prone to site. This intervention is done to:
the respiratory system developing ketosis
30. Mrs. Seva asked for instructions for skin care for her c. Applying no suction while inserting the catheter b. Type II (NIDDM) is more common and is also a. Reduce the need to change dressing frequently
mother who has urinary incontinence and is almost d. Rotating catheter as it is inserted with gentle suction preventable compared to Type I (IDDM) diabetes which b. Allow the pus to surface faster
always in bed. Your instruction would focus on is genetic in etiology c. Protect the wound from micro organisms in the air
prevention of skin irritation and breakdown by 35. Myrna has difficulty breathing when on her back c. Type I (IDDM) is characterized by fasting d. Promote hemostasis
and must sit upright in bed to breath, effectively and hyperglycemia
a. Using thick diapers to absorb urine well comfortably. The nurse documents this condition as: d. Type II (IDDM) is characterized by abnormal immune 45. After the treatment, the client is sent home and
b. Drying the skin with baby powder to prevent or mask response asked to come back for follow-up care. Your
the smell of ammonia a. Apnea responsibilities when the client is to be discharged
c. Thorough washing, rising and during of skin area that b. Orthopnea 40. Lifestyle-related diseases in general share areas include the following EXCEPT:
get wet with urine c. Dyspnea common risk factors. These are the following except
d. Making sure that linen are smooth and dry at all times d. Tachypnea a. physical activity a. Encouraging the client to go to the, outpatient clinic
b. smoking for follow up care
Situation 7 - Using Maslow's need theory, Airway, Situation 8 - You are assigned to screen for c. genetics b. Accurate recording, of treatment done and
Breathing and Circulation are the physiological needs hypertension: Your task is to take blood pressure d. nutrition instructions given to client
vital to life. The nurse's knowledge and ability to identify readings and you are informed about avoiding the c. Instructing the client to see you after discharge for
and immediately intervene to meet these needs is common mistakes in BP taking that lead to 'false or Situation 9 - Nurse Rivera witnesses a vehicular accident further assistance
important to save lives. inaccurate blood pressure readings. near the hospital where she works. She decides to get d. Providing instructions regarding wound care
involved and help the victims of the accident.
31. Which of these clients has a problem with the 36. When taking blood pressure reading the cuff should Situation 10 - While working in the clinic, a new client,
transport of oxygen from the lungs to the tissues: be: 41. Her priority nursing action would be to: Geline, 35 years old, arrives for her doctor's
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appointment. As the clinic nurse, you are to assist the Mr. Dizon smokes and drinks coffee. When taking the
client fiil up forms, gather data and make an assessment. a. Caffeine products affect the central nervous system a. Transfer a client from bed to chair blood pressure of a client who recently smoked or
and may cause the mother to have a "nervous b. Change IV infusions drank coffee, how long should be the nurse wait before
46. The nurse purpose of your initial nursing interview breakdown" c. Irrigation of a nasogastric tube taking the client’s blood pressure for accurate reading?
is to: b. Malnutrition and its possible effects on growth and d. Take vital signs
development problems in the unborn fetus a. 15 minutes
a. Record pertinent information in the client chart for c. Caffeine causes a stimulant effect on both the mother 55. You made a mistake in giving the medicine to the b. 30 minutes
health team to read and the baby wrong client You notify the client’s doctor and write an c. 1 hour
b Assist the client find solutions to her health concerns d. Studies show conclusively that caffeine causes mental incident report. You are demonstrating: d. 5 minutes
c. Understand her lifestyle, health needs and possible retardation
problems to develop a plan of care a. Responsibility 60. While the client has the pulse oximeter on his
d. Make nursing diagnoses for identified health problems 50. Your health education plan for Geline stresses b. Accountability fingertip, you notice that the sunlight is shining on .the
proper diet for a pregnant woman and the prevention c. Authority area where the oximeter is. Your action will be to:
47. While interviewing Geline, she starts to moan and of non-communicable diseases that are influenced by d. Autocracy
doubles up in pain, She tells you that this pain occurs her lifestyle these include of the following EXCEPT: a. Set and turn on the alarm of the oximeter
about an hour after taking black coffee without Situation 12 – Mr. Dizon, 84 years old, is brought to the b. Do nothing since there is no identified problem
breakfast for a few weeks now. You will record this as a. Cardiovascular diseases .Emergency Room for complaint of hypertension flushed c. Cover the fingertip sensor with a towel or bedsheet
follows: b. Cancer face, severe headache, and nausea. You are doing the d. Change the location of the sensor every four hours
c. Diabetes Mellitus initial assessment of vital signs.
a. Claims to have abdominal pains after intake of coffee d. Osteoporosis Situation 13 - The nurse's understanding of ethico-legal
unrelieved by analgesics 56. You are to measure the client’s initial blood responsibilities will guide his/her nursing practice.
b. After drinking coffee, the client experienced severe Situation 11 - Management of nurse practitioners is pressure reading by doing all of the following EXCEPT:
abdominal pain done by qualified nursing leaders who have had clinical 61. The principles that .govern right and proper
c. Client complained of intermittent abdominal pain an experience and management experience. a. Take the blood pressure reading on both arms for conducts of a person regarding life, biology and the
hour after drinking coffee comparison health professions is referred to as:
d. Client reported abdominal pain an hour after drinking 51. An example of a management function of a nurse is: b. Listen to and identify the phases of Korotkoff’s sounds
black coffee for three weeks now c. Pump the cuff up to around 50 mmHg above the point a. Morality
a. Teaching patient do breathing and coughing exercises where the pulse is obliterated b. Religion
48. Geline tells you that she drinks black coffee b. Preparing for a surprise party for a client d. Observe procedures for infection control c. Values
frequently within the day to "have energy and be wide c. Performing nursing procedures for clients d. Bioethics
awake" and she eats nothing for breakfast and eats d. Directing and evaluating the staff nurses 57. A pulse oximeter is attached to Mr. Dizon’s finger
strictly vegetable salads for lunch and dinner to lose to: 62. The purpose of having nurses’ code of ethics is:
weight. She has lost weight during the past two weeks, 52. Your head nurse in the unit believes that the staff
in planning a healthy balanced diet with Geline, you nurses are not capable of decision making so she makes a. Determine if the client’s hemoglobin level is low and if a. Delineate the scope and areas of nursing practice
will: the decisions for everyone without consulting anybody. he needs blood transfusion b. Identify nursing action recommended for specific
This type of leadership is: b. Check level of client’s tissue perfusion healthcare situations
a. Start her off with a cleansing diet to free her body of c. Measure the efficacy of the client’s anti hypertensive c. To help the public understand professional conduct,
toxins then change to a vegetarian, diet and drink plenty a. Laissez faire leadership medications expected of nurses
of fluids b. Democratic leadership d. Detect oxygen saturation of arterial blood before d. To define the roles and functions of the health care
b. Plan a high protein, diet; low carbohydrate diet for her c. Autocratic leadership symptoms of hypoxemia develops giver, nurses, clients
considering her favorite food d. Managerial leadership
c. Instruct her to attend classes in nutrition to find food 58. After a few hours in the Emergency Room, Mr. 63. The most important nursing responsibility where
rich in complex carbohydrates to maintain daily high 53. When the head nurse in your ward plots and Dizon is admitted to the ward with an order of hourly ethical situations emerge in patient care is to:
energy level approves your work schedules and directs your work, monitoring of blood pressure. The nurse finds that the
d. Discuss with her the importance of eating a variety of she is demonstrating: cuff is too narrow and this will cause the blood pressure a. Act only when advised that the action is ethically
food from the major food groups with plenty of fluids reading to be: sound
a. Responsibility b. Not take sides remain neutral and fair
49. Geline tells you that she drinks 4-5 cups of black b. Delegation a. Inconsistent c. Assume that ethical questions are the responsibility: of
coffee and diet cola drinks. She also smokes up to a c. Accountability b. low systolic and high diastolic pressure the health team
pack of cigarettes daily. She confesses that she is in her d. Authority c. higher than what the reading should be d. Be accountable for his or her own actions
2nd month of pregnancy but she does not want to d. lower than what the reading should be
become fat that is why she limits her food intake. You 54. The following tasks can be safely delegated' by a 64. You inform the patient about his rights which
warn or caution her about which of the following? nurse to a non-nurse health worker EXCEPT: 59. Through the client’s health history, you gather that include the following EXCEPT:
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a. Have the registered nurse, family spokesperson, nurse immediate concerns of the group. Your presentation nitroglycerin to your client. The following important
a. Right to expect reasonable continuity of care supervisor and doctor sign for a group of young mothers would be best if you guidelines to observe EXCEPT:
b. Right to consent to or decline to participate in b. Have two nurses validate the phone order, both focus on:
research studies or experiments nurses sign the order and the doctor should sign his a. Apply to hairlines clean are of the skin not subject to
c. Right to obtain information about another patient order within 24 hours. a. diets limited in salt and fat much wrinkling
d. Right to expect that the records about his care will be c. Have the registered nurse, family and doctor sign the b. harmful effect on drugs and alcohol intake b. Patches may be applied to distal part of the
treated as confidential order c. commercial preparation of dishes extremities like forearm
d. Have 1 nurse take the order and sign it and have the d. cooking demonstration and meal planning c. Change application and site regularly to prevent
65. The principle states that a person has unconditional doctor sign it within 24 hours irritation of the skin
worth and has the capacity to determine his own 74. Cancer cure is dependent on d. Wear gloves to avoid any medication of your hand
destiny. 69. To ensure the client safety before starting blood
transfusion the following are needed before the a. use of alternative methods of healing 79. You will be applying eye drops to Miss Romualdez.
a. Bioethics procedure can be done EXCEPT: b. watching out for warning signs of cancer After checking all the necessary information and
b. Justice c. proficiency in doing breast self-examination cleaning the affected eyelid and eyelashes you
c. Fidelity a. take baseline vital signs d. early detection and prompt treatment administer the ophthalmic drops by instilling the eye
d. Autonomy b. blood should be warmed to room temperature for 30 drops.
minutes before blood transfusion is administered 75. The role of the health worker in health education is
Situation 14 – Your director of nursing wants to improve c. have two nurses verify client identification, blood to: a. directly onto the cornea
the quality of health care offered in the hospital. As a type, unit number and expiration date of blood b. pressing on the lacrimal duct
staff nurse in that hospital you know that this entails d. get a consent signed for blood transfusion a. report incidence of non-communicable disease to c. into the outer third of the lower conjunctival sac
quality assurance programs. community health center d. from the inner canthus going towards the side of the
70. Part of standards of care has to do with the use of b. educate as many people about warning signs of non- eye
66. The following mechanisms can be utilized as part of restraints. Which of the following statements is NOT communicable diseases
the quality assessment program of your hospital true? c. focus on smoking cessation projects 80. When applying eye ointment, the following
EXCEPT: d. monitor clients with hypertension guidelines apply EXCEPT:
a. Doctor’s order for restraints should be signed within
a. Patient satisfaction surveys provided 24 hours Situation 16 – You are assigned to take care of 10 a. squeeze about 2 cm of ointment and gently close but
b. Peer review clinical records of care of client b. Remove and reapply restraints every two hours patients during the morning shift. The endorsement not squeeze eye
c. RO of the Nursing Intervention Classification c. Check client’s pulse, blood pressure and circulation includes the IV infusion and medications for these b. apply ointment from the inner canthus going outward
d. every four hours clients. of the affected eye
d. Offer food and toileting every two hours c. discard the first bead of the eye ointment before
67. The nurse of the Standards of Nursing Practice is 76. Mr. Felipe, 36 years old is to be given 2700ml of application because the tube likely to expel more than
important in the hospital. Which of the following Situation 15 – During the NUTRITION EDUCATION class D5RL to infuse for 18 hours starting at 8am. At what desired amount of ointment
statements best describes what it is? discussion a 58 year old man, Mr. Bruno shows increased rate should the IV fluid be flowing hourly? d. hold the tube above the conjunctival sac do not let tip
interest. touch the conjuctiva
a. These are statements that describe the maximum or a. 100 ml/hour
highest level of acceptable performance in nursing 71. Mr. Bruno asks what the "normal" allowable salt b. 210 ml/hour Situation 17 – The staff nurse supervisor request all the
practice. intake is. Your best response to Mr. Bruno is: c. 150 ml/hour staff nurses to “brainstorm” and learn ways to instruct
b. It refers to the scope of nursing as defined in Republic d. 90 ml/hour diabetic clients on self-administration of insulin. She
Act 9173 a. 1 tsp of salt/day with iodine and sprinkle of MSG wants to ensure that there are nurses available daily to
c. It is a license issued by the Professional Regulation b. 5 gms per day or 1 tsp of table salt/day 77. Mr. Atienza is to receive 150mg/hour of D5W IV do health education classess.
Commission to protect the public from substandard c. 1 tbsp of salt/day with some patis and toyo infusion for 12 hours for a total of 1800ml. He is also
nursing practice. d. 1 tsp of salt/day but not patis or toyo losing gastric fluid which must be replaced every two 81. The plan of the nurse supervisor is an example of
d. The Standards of care includes the various steps of the hours. Between 8am to 10am. Mr. Atienza has lost
nursing process and the standards of professional 72. Your instructions to reduce or limit salt intake 250ml of gastric fluid. How much fluid should he a. in service education process
performance. include all the following EXCEPT: receive at 11am? b. efficient management of human resources
a. eat natural food with little or no salt added c. increasing human resources
68. You are taking care of critically ill client and the b. limit use of table salt and use condiments instead a. 350 ml/hour d. primary prevention
doctor in charge calls to order a DNR (do not c. use herbs and spices b. 275 ml/hour
resuscitate) for the client. Which of the following is the d. limit intake of preserved or processed food c. 400 ml/hour 82. When Mrs. Guevarra, a nurse, delegates aspects of
appropriate action when getting DNR order over the d. 200 ml/hour the clients care to the nurse-aide who is an unlicensed
phone? 73. Teaching strategies and approaches when giving staff, Mrs. Guevarra.
nutrition education is influenced by age, sex and 78. You are to apply a transdermal patch of
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a. makes the assignment to teach the staff member d. wellness center b. "Why do you; sound so scared? It is just a cast and it's
b. is assigning the responsibility to the aide but not the not painful"
accountability for those tasks 88. Part of teaching client in health promotion is c. "You seem to be concerned about being in a cast."
c. does not have to supervise or evaluate the aide responsibility for one’s health. When Danica states she d. "Based on my assessment, there doesn’t seem to be a
d. most know how to perform task delegated need to improve her nutritional status this means: fracture."
83. Connie, the-new nurse, appears tired and sluggish a. Goals and interventions to be followed by client are
and lacks the enthusiasms she give six weeks ago when based on nurse's priorities
she started the job. The nurse supervisor should: b. Goals and intervention developed by nurse and client
should be approved by the doctor
a. empathize with the nurse and listen to her c. Nurse will decide goals and, interventions needed to
b. tell her to take the day off meet client goals
c. discuss how she is adjusting to her new job d. Client will decide the goals and interventions required
d. ask about her family life to meet her goals
84. Process of formal negotiations of working 89. Nurse Beatrice is providing tertiary prevention to
conditions between a group of registered nurses and Mrs. De Villa. An example of tertiary provestion is:
employer is:
a. Marriage counseling
a. grievance b. Self-examination for breast cancer
b. arbitration c. Identifying complication of diabetes
c. collective bargaining d. Poison, control
d. strike
90. Mrs. Ostrea has a schedule for Pap Smear. She has a
85. You are attending a certification program on strong family history of cervical cancer. This is an
cardiopulmonary resuscitation (CPR) offered and example of:
required by the hospital employing you. This is;
a. tertiary prevention
a. professional course towards credits b. secondary prevention
b. in-service education c. health screening
c. advance training d. primary prevention
d. continuing education
Situation: 19 - Ronnie has a vehicular accident where he
Situation 18 - There are various developments in health sustained injury to his left ankle. In the Emergency
education that the nurse should know about. Room, you notice how anxious he looks.
86. The provision of health information in the rural 91. You establish rapport with him and to reduce his
areas nationwide through television and radio anxiety you initially
programs and video conferencing is referred to as:
a. Take him to the radiology, section for X-ray of affected
a. Community health program extremity
b. Telehealth program b. Identify yourself and state your purpose in being with
c. Wellness program the client
d. Red cross program c. Talk to the physician for an order of Valium
d. Do inspection and palpation to check extent of his
87. A nearby community provides blood pressure injuries
screening, height and weight measurement smoking
cessation classes and aerobics class services. This type 92. While doing your assessment, Ronnie asks you "Do I
of program is referred to as: have a fracture? I don't want to have a cast.” The most
appropriate nursing response would be:
a. outreach program
b. hospital extension program a. "You have to have an X-ray first to know if you have a
c. barangay health center fracture."
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ANSWER KEY - FOUNDATION OF PROFESSIONAL 51. D calorin intake for breast-feeding. By how much should a
NURSING PRACTICE 52. C lactating mother increase her caloric intake during the
53. D COMMUNITY HEALTH NURSING AND CARE OF THE first 6 months after birth?
1. C 54. B MOTHER AND CHILD
2. B 55. B a. 350 kcal/day
3. D 56. C Situation 1 - Nurse Minette is an independent Nurse b. 5CO kcal/day
4. D 57. D Practitioner following-up referred clients in their c. 200 kcal/day
5. B 58. C respective homes. Here she handles a case of d. 1,000 kcal/day
6. B 59. B POSTPARTIAL MOTHER AND FAMILY focusing on HOME
7. C 60. C CARE. Situation 2 - As the CPES is applicable for all professional
8. D 61. D nurse, the professional growth and development of
9. B 62. C 1. Nurse Minette needs to schedule a first home visit to Nurses with specialties shall be addressed by a Specialty
10. B 63. D OB client Leah. When is a first home-care visit typically Certification Council.
11. B 64. C made? The following questions apply to these special groups of
12. C 65. D nurses.
13. C 66. D a. Within 4 days after discharge
14. D 67. A b. Within 24 hours after discharge 6. Which of the following serves as the legal basis and
15. A 68. D c. Within 1 hour after discharge statute authority for the Board of nursing to
16. A 69. D d. Within 1 week of discharge promulgate measures to effect the creation of a
17. C 70. C Specialty Certification Council and promulgate
18. B 71. B 2. Leah is developing constipation from being on bed professional development programs for this group of
19. A 72. B rest. What measures would you suggest she take to nurse-professionals?
20. C 73. D help prevent this?
21. D 74. D a. R.A. 7610
22. C 75. B a. Eat more frequent small meals instead of three large b. R.A. 223
23. D 76. C one daily c. R.A. 9173
24. D 77. - b. Walk for at least half an hour daily to stimulate d. R.A. 7164
25. C 78. B peristalsis
26. D 79. B c. Drink more milk, increased calcium intake prevents 7. By force of law, therefore, the PRC-Board of Nursing
27. C 80. C constipation released Resolution No. 14 Series of the entitled:
28. D 81. C d. Drink eight full glasses of fluid such as water daily "Adoption of a Nursing Specialty Certification Program
29. D 82. B and Creation of Nursing Specialty Certification Council."
30. C 83. C 3. If you were Minette, which of the following actions, This rule-making power is called:
31. B 84. C would alert you that a new mother is entering a
32. C 85. B postpartial at taking-hold phase? a. Quasi-Judicial Power
33. C 86. B b. Regulatory Power
34. C 87. A a. She urges the baby to stay awake so that she can c. Quasi/Legislative Power
35. B 88. D breast-feed him in her d. Executive/Promulgation Power
36. D 89. C b. She tells you she was in a lot of pain all during labor
37. D 90. B c. She says that she has not selected a name fir the baby 8. Under the PRC-Board of Nursing Resolution
38. B 91. B as yet promulgating the adoption of a Nursing Specialty-
39. B 92. C d. She sleeps as if exhausted from the effort of labor Certification Program and Council, which two (2) of the
40. C following serves as the strongest for its enforcement?
41. D 4. At 6-week postpartum visit what should this (a) Advances made in science aid technology have
42. B postpartial mother's fundic height be? provided the climate for specialization in almost all
43. D aspects of human endeavor and
44. D a. Inverted and palpable at the cervix (b) As necessary consequence, there has emerged a new
45. C b. Six fingerbreadths below the umbilicus concept known as globalization which seeks to remove
46. C c. No longer palpable on her abdomen barriers in trade, .industry and services imposed by the
47. D d. One centimeter above the symphysis pubis national laws of countries all over the world; and
48. D (c) Awareness of this development should impel the
49. B 5. This postpartal mother wants to loose the weight she nursing sector to prepare our people in the services
50. D gained in pregnancy, so she is reluctant to increase her sector to meet .the above challenges; and
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(d) Current trends of specialization in nursing practice be acceptable TRUTHS applied to Community Health 16. Transmission of HIV from an infected individual to a. Prostaglandins released from the cut fallopian tubes
recognized by; the International Council of Nurses (ICN) Nursing Practice. another person occurs: can kill sperm
of which the Philippines is a member for the benefit of b. Sperm cannot enter the uterus, because the cervical
the Filipino in terms of deepening and refining nursing 11. Which of the following is the primary focus of a. Most frequency in nurses with needlesticks entrance is blocked
practice and enhancing the quality of nursing care. community health nursing practice? b. Only if there is a large viral load in the blood c. Sperm can no longer reach the ova, because the
c. Most commonly as a result of sexual contact fallopian tubes are blocked
a. b & c are strong justification a. Cure of illnesses d. In all infants born to women with HIV infection d. The ovary no longer releases ova, as there is no where
b. a & b are strong justification b. Prevention of illness for them to go
c. a & c are strong justification c. Rehabilitation back to health 17. The medical record of a client reveals a condition in
d. a & d are strong justification d. Promotion of health which the fetus cannot pass through the maternal 22. The Dators are a couple undergoing testing for
pelvis. The nurse interprets this as: infertility. Infertility is said to exist when:
9. Which of the following is NOT a correct statement as 12. In community health nursing, which of the following
regards Specialty Certification? is our unit of service as nurses? a. Contracted pelvis a. a woman has no uterus
b. Maternal disproportion b. a woman has no children
a. The Board of Nursing intended to create the Nursing a. The Community c. Cervical insufficiency c. a couple has been trying to conceive for 1 year
Specialty Certification Program as a means of b. The Extended Members of every family d. Fetopelvic disproportion d. a couple has wanted a child for 6 months
perpetuating the creation of an elite force of Filipino c. The individual members of the Barangay
Nurse Professionals d. The Family 18. The nurse would anticipate a cesarean birth for a 23. Another client names Lilia is diagnosed as having
b. The Board of Nursing shall oversee the administration client who has which infection present at the onset of endometriosis. This condition interferes with the
of the NSCP through the various Nursing Specialty 13. A very important part of the Community Health labor? fertility because:
Boards which will eventually, be created Nursing Assessment Process includes
c. The Board of Nursing at the time exercised their a. Herpes simplex virus a. endometrial implants can block the fallopian tubes
powers under R.A. 7164 in order to adopt the creation of a. the application of professional judgment in estimating b. Human papilloma virus b. the uterine cervix becomes inflamed and swollen
the Nursing Specialty Certification /council and Program importance of facts to family and community c. Hepatitis c. ovaries stop producing adequate estrogen
d. The Board of Nursing consulted nursing leaders of b. evaluation structures arid qualifications of health d. Toxoplasmosia d. pressure on the pituitary leads to decreased FSH levels
national nursing associations and other concerned center team
nursing groups which later decided to ask a special group c. coordination with other sectors in relation to health 19. After a vaginal examination, the nurse»e 24. Lilia is scheduled to have a hysterosalpingogram.
of nurses of .the program for nursing specialty concerns determines that the client's fetus is in an occiput Which of the following, instructions would you give her
certification d. carrying out nursing procedures as per plan of action posterior position. The nurse would anticipate that the regarding this procedure?
client will have:
10. The NSCC was created for the purpose of 14. In community health nursing it is important to take a. She will not be able to conceive for 3 months after the
implementing the Nursing Specialty policy under the into account the family health with an equally a. A precipitous birth procedure
direct supervision and stewardship of the Board of important need to perform ocular inspection of the b. Intense back pain b. The sonogram of the uterus will reveal any tumors
Nursing. Who shall comprise the NSCC? areas activities which are powerful elements of: c. Frequent leg cramps present
d. Nausea and vomiting c. Many women experience mild bleeding as an after
a. A Chairperson who is the current President of the APO a. evaluation effect
a member from .the Academe, and the last member b. assessment 20. The rationales for using a prostaglandin gel for a d. She may feel some cramping when the dye is inserted
coming from the Regulatory Board c. implementation client prior to the induction of labor is to:
b. The Chairperson and members of the Regulatory d. planning 25. Lilia's cousin on the other hand, knowing nurse
Board ipso facto acts as the CPE Council a. Soften and efface the cervix Lorena's specialization asks what artificial insemination
c. A Chairperson, chosen from among the Regulatory 15. The initial step in the PLANNING process in order to b. Numb cervical' pain receptors by donor entails. Which would be your best answer if
Board Members, a Vice Chairperson appointed by the engage in any nursing project or parties at the c. Prevent cervical lacerations you were Nurse Lorena?
BON at-large; two other members also chosen at-large; community level involves: d. Stimulate uterine contractions
and one representing the consumer group a. Donor sperm are introduced vaginally into the uterus
d. A Chairperson who is the President of the Association a. goal-setting Situation 5 - Nurse Lorena is a Family Planning and or cervix
from the Academe; a member from the Regulatory b. monitoring Infertility Nurse Specialist and currently attends to b. Donor sperm are injected intra-abdominally into each
Board, and the last member coming from the APO c. evaluation of data FAMILY PANNING CLIENTS AND INFERTILE COUPLES. The ovary
d. provision of data following conditions pertain to meeting the nursing of c. Artificial sperm are injected vaginally to test tubal
Situation 3 - Nurse Anna is a new BSEN graduate and has this particular population group. patency
just passed her Licensure Examination for Nurses in the Situation 4 - Please continue responding as a d. The husband's sperm is administered intravenously
Philippines. She has likewise been hired as a new professional nurse in these other health situations 21. Dina, 17 years old, asks you how a tubal ligation weekly
Community Health Nurse in one of the Rural Health through the following questions. prevents pregnancy. Which would be the best answer?
Units in their City, which of the following conditions may Situation 6 - There are other important basic knowledge
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in the performance of our task as Community Health pertalos to documentation/records management. b. Medicine and Treatment Record a. A nurse withholding harmful information to the family
Nurse in relation to IMMUNIZATION these include: c. Nursing Health History and Assessment Worksheet members of a patient
31. This special form used when the patient is admitted d. Nursing Kardex b. A nurse declining commission sent by a doctor for her
26. The correct temperature to store vaccines in a to the unit. The nurse completes, the information in referral
refrigerator is: this records particularly his/her .basic personal data, 35. Most nurses regard this as conventional recording c. A nurse endorsing a person running for congress
current illness, previous health history, health history of the date, time and mode by which the patient leaves d. Nurse Reviewers and/or nurse review center
a. between -4 deg C and +8 deg C of the family, emotional profile, environmental history a healthcare unit but this record includes importantly, managers who pays a considerable amount of cash for
b. between 2 deg C and +8 deg C as well as physical assessment together with nursing directs of planning for discharge that starts soon after reviewees who would memorize items from the
c. between -8 deg C and 0 deg C diagnosis on admission. What do you call this record? the' person is admitted to a healthcare institution, it is Licensure exams and submit these to them after the
d. between -8 deg C and +8 deg C accepted that collaboration or multidisciplinary examination
a. Nursing Kardex involvement (of all members of the health team) in
27. Which of the following vaccines is not done by b. Nursing Health History and Assessment Worksheet discharge results in comprehensive care. What do you 39. A nurse should be cognizant that professional
intramuscular (IM) injection? c. Medicine and Treatment Record call this? programs for specialty certification by the Board of
d. Discharge Summary Nursing are accredited through the
a. Measles vaccine a. Discharge Summary
b. DPT 32. These, are sheets/forms which provide an efficient b. Nursing Kardex a. Professional Regulation Commission
c. Hepa B vaccines and time saving way to record information that must c. Medicine and Treatment Record b. Nursing Specialty Certification Council
d. DPT be obtained repeatedly at regular and/or short d. Nursing Health History and Assessment Worksheet c. Association of Deans of Philippine Colleges of Nursing
intervals, of .time. This does not replace the progress d. Philippine Nurse Association
28. This vaccine content is derived from RNA notes; instead this record of information on vital signs, Situation 8 - As Filipino Professional Nurses we must be
recombinants: intake and output, treatment, postoperative care, knowledgeable, about the Code of Ethics for Filipino 40. Mr. Santos, R.N. works in a nursing home, and he
postpartum care, and diabetic regimen, etc., this is Nurses and practice these by heart. The next questions knows that one of his duties is to be an advocate for his
a. Measles used whenever specific measurements or observations pertain to this Code of Ethics. patients. Mr. Santos knows a primary duty of an
b. Tetanus toxoids are needed to-be documented repeatedly. What is advocate is to:
c. Hepatitis B vaccines this? 36. Which of the following is TRUE about the Code of
d. DPT Ethics of Filipino Nurses? a. act as the patient's legal representative
a. Nursing Kardex b. complete all nursing responsibilities on time
29. This is the vaccine needed before a child reaches b. Graphic Flow sheets a. The Philippine Nurses Association for being the c. safeguard the well being of every patient
one (1) year in order for him/her to qualify as a "fully c. Discharge Summary accredited professional organization was given the d. maintain the patient's right to privacy
immunized child". d. Medicine and Treatment Record privilege to formulate a Code of Ethics which the Board
of Nurses promulgated Situation 9 - Nurse Joanna works as an OB-Gyne Nurse
a. DPT 33. These records show all medications and treatment b. Code of Nurses was first formulated in 1982 published and attends to several HIGH-RISK PREGNANCIES:
b. Measles provided on a repeated basis. What do you call this in the Proceedings of the Third Annual Convention of the Particularly women with preexisting of Newly Acquired
c. Hepatitis B record? PNA House of Delegates illness. The following conditions apply.
d. BCG c. The present code utilized the Code of Good
a. Nursing Health History and Assessment Worksheet Governance for the Professions in the Philippines 41. Bernadette is a 22-year old woman. Which
30. Which of the following dose of tetanus toxoid is b. Discharge Summary d. Certificate of Registration of registered nurses; may be condition would make her more prone than others to
given to the mother to protect her .infant from c. Nursing Kardex revoked or suspended for violations of any provisions of developing a Candida infection during pregnancy?
neonatal tetanus and likewise provide 10 years d. Medicine and Treatment Record the Code of Ethics
protection for the mother? a. Her husband plays gold 6 days a week
34. This flip-over card is usually kept in a portable file at 37. Based on the Code of Ethics for Filipino Nurses, b. She was over 35 when she became pregnant
a. Tetanus toxoid 3 the Nurses Station. It has 2-parts: the activity and what is regarded as the hallmark of nursing c. She usually drinks tomato juice for breakfast
b. Tetanus toxoid 2 treatment section and a nursing care plan section. This responsibility and accountability? d. She has developed gestational diabetes
c. Tetanus toxoid 1 carries information about basic demographic data,
d. Tetanus toxoid 4 primary medical diagnosis, current orders of the a. Human rights of clients, regardless of creed and 42. Bernadette develops a deep-vein thrombosis
physician to be carried out by the nurse, written gender following an auto accident and is prescribed heparin
Situation 7 - Records contain those, comprehensive nursing care plan, nursing orders, scheduled tests and b. The privilege of being a registered professional nurses sub-Q. What should Joanna educate her about in regard
descriptions of patient's health conditions and needs and procedures, safety precautions in-patient care and c. Health, being a fundamental right of every individual to this?
at the same serve as evidences of every nurse's factors related to daily living activities/ this record is d. Accurate documentation of actions and outcomes
accountability in the, care giving process. Nursing used in the charge-of-shift reports or during the beside a. Some infants will be born with allergic symptoms to
records normally differ from institution to, institution rounds or walking rounds. What record is this? 38. Which of the following nurses behavior is regarded heparin
nonetheless they follow similar patterns of .meeting as a violation of the Code of Ethics of Filipino Nurses? b. Her infant will be born with scattered petechiae on his
needs for specifics, types of information. The following a. Discharge Summary trunk
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c. Heparin can cause darkened skin in newborns children with cough a. At 2 years you may contraindication to immunization?
d. Heparin does not cross the placenta and so does not c. Refer to the doctor b. As early as 1 year old
affect a fetus d. Teach the mother how to count her child's bearing c. When she's 3- years old a. do not give DPT2 or DPT3 to a child who has
d. When she's 6 years old? convulsions within 3 days of DPT1
43. The cousin of Bernadette with sickle-cell anemia 47. In responding to the care concerns of children with b. do not give BOG if the child has known hepatitis .
alerted Joanna that she may need further instruction severe disease, referral to the hospital of the essence 52. You typically gag children to inspect the back of c. do not give OPT to a child who has recurrent
on prenatal care. Which statement signifies this fact? especially if the child manifests which of the following? their throat. When is it important NOT to solicit a gag convulsion or active neurologic disease
reflex? d. do not give BCG if the child has known AIDS
a. I've stopped jogging so I don't risk becoming a. Wheezing
dehydrated b. Stopped bleeding a. when a girl has a geographic tongue 58. Which of the following statements about
b. I take an iron pull every day to help grown new red c. Fast breathing b. when a boy has a possible inguinal hernia immunization is NOT true:
blood cells d. Difficulty to awaken c. when a child has symptoms of epiglottitis
c. I am careful to drink at least eight glasses of fluid d. when children are under 5 years of age a. A child with diarrhea who is due for OPV should
everyday 48. Which of the following is the most important receive the OPV and make extra dose on the next visit
d. 1 understand why folic acid is important for red cell responsibility of a nurse in the prevention of necessary 53. Baby John was given a drug at birth to reverse the b. There is no contraindication to immunization if the
formation deaths from pneumonia and other severe diseases? effects of a narcotic given to his mother in' labor. What child is well enough to go home
drug is commonly used for this? c. There is no contraindication to immunization if the
44. Bernadette routinely takes acetylsalicylic acid a. Giving of antibiotics child is well enough to go home and a child should be
(aspirin) for arthritis. Why should she limit or b. Taking of the temperature of the sick child a. Naloxone (Narcan) immunized in the health center before referrals are both
discontinue this toward the end of pregnancy? c. Provision of Careful Assessment b. Morphine Sulfate correct
d. Weighing of the sick child c. Sodium Chloride d. A child should be immunized in the center before
a. Aspirin can lead to deep vein thrombosis following d. Penicillin G referral
birth 49. You were able to identify factors that lead to
b. Newborns develop a red rash from salicylate toxicity respiratory problems in the community where your 54. Why are small-for-gestational-age newborns at risks 59. A child with visible severe wasting or severe palmar
c. Newborns develop withdrawal headaches from health facility serves. Your primary role therefore in for difficulty maintaining body temperature? pallor may be classified as:
salicylates order to reduce morbidity due to pneumonia is to:
d. Salicyates can lead to increased maternal bleeding at a. They do not have as many fat stores as other infant’s a. moderate malnutrition/anemia
childbirth a. Teach mothers how to recognize early signs and b. They are more active than usual so throw off covers b. severe malnutrition/anemia
symptoms of pneumonia c. Their skin is more susceptible to conduction of cold c. not very tow weight no anemia
45. Bernadette received a laceration on her leg from b. Make home visits to sick children d. They are preterm so are born relatively small in size d. anemia/very low weight
her automotive accident. Why are lacerations of lower c. Refer cases to hospitals
extremities potentially more serious in pregnant d. Seek assistance and mobilize the BHWs to have a 55. Baby John develops hyperbilirubinemia. What is a 60. A child who has some palmar pallor can be
women than others? meeting with mothers method used to treat hyperbilirubinemia in a newborn? classified as:
a. Lacerations can provoke allergic responses because of 50. Which of the following is the principal focus on the a. Keeping infants in a warm arid dark environment a. moderate anemia/normal weight
gonadothropic hormone CARI program of the Department of Health? b. Administration of a cardiovascular stimulant b. severe malnutrition/anemia
b. Increased bleeding can occur from uterine pressure on c. Gentle exercise to stop muscle breakdown c. anemia/very low weight
leg veins a. Enhancement of health team capabilities d. Early feeding to speed passage of meconium d. not very low eight to anemia
c. A woman is less able to keep the laceration clean b. Teach mothers how to detect signs and where to refer
because o f her fatigue c. Mortality reduction through early detection Situation 12 - You are the nurse in the Out-Patient- Situation 13 - Nette, a nurse palpates the abdomen of
d. Healing is limited during pregnancy, so these will not d. Teach other community health workers how to assess Department and during your shift you encountered Mrs. Medina, a primigravida. She is unsure of the date of
heal until after birth patients multiple children's condition. The following questions her last menstrual period. Leopold's Maneuver is done.
apply. The obstetrician told mat she appears to be 20 weeks
Situation 10 - Still in your self-managed Child Health Situation 11 - You are working as a Pediatric Nurse in pregnant. .
Nursing Clinic, your encounter these cases pertaining to your own Child Health Nursing Clinic, the following cases 56. You assessed a child with visible severe wasting, he
the CARE OF CHILDREN WITH PULMONARY AFFECTIONS. pertain to ASSESSMENT AND CARE OP THE NEWBORN AT has: 61. Nette explains this because the fundus is:
RISK conditions.
46. Josie brought her 3-rnonths old child to your clinic a. edema a. At the level the umbilicus, and the fetal heart can be
because of cough and colds. Which of the following is 51. Theresa, a mother with a 2 year old daughter asks, b. LBM heard with a fetoscope
your primary action? "at what are can I be able to take the blood pressure of c. kwashiorkor b. 18 cm, and the baby is just about to move
my daughter as a routine procedure since hypertension d. marasmus c. is just over the symphysis, and fetal heart cannot be
a. Give contrimoxazole tablet or syrup is common in the family?" Your answer to this is: heard
b. Assess the patient using the chart on management of 57. Which of the following conditions is NOT true about d. 28 cm, and fetal heart can be heard with a Doppler
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b. Nifedipine a. a requirement for home visits and management from the Barangay Level to the Local
62. In doing Leopold's maneuver palpation which c. Butorphanol b. an essential and indispensable equipment of the Government/Municipal City Level.
among the following is NOT considered a good d. Diazepam community health nurse
preparation? c. contains basic medications and articles used by the 76. The following statements can correctly be made
67. RhoGAM is given to Rh-negative women to prevent community health nurse about Organization and management?
a. The woman should lie in a supine position wither maternal sensitization from occurring. The nurse is d. a tool used by the Community health nurse is
knees flexed slightly aware that in addition to pregnancy, Rh-negative rendering effective nursing procedure during a home A. An organization (or company) is people. Values make
b. The hands of the nurse should be cold so that women would also receive this medication after which visit people persons: values give vitality, meaning and
abdominal muscles would contract and tighten of the following? direction to a company. As the people of an organization
c. Be certain that your hands are warm (by washing them 72. What is the rationale in the use of bag technique value, so the company becomes.
in warm water first if necessary) a. Unsuccessful artificial insemination procedure during home visit? B. Management is the process by which administration
d. The woman empties her bladder before palpation b. Blood transfusion after hemorrhage achieves its mission, goals, and objectives
c. Therapeutic or spontaneous abortion a. It helps render effective nursing care to clients or C. Management effectiveness can be measured in terms
63. In her pregnancy, she experienced fatigue and d. Head injury from a car accident other members of the family of accomplishment of the purpose of the organization
drowsiness. This probably occurs because: b. It saves time and effort of the nurse in the while management efficiency is measured in terms of
68. Which of the following would the nurse include performance of nursing procedures the satisfaction of individual motives
a. of high blood pressure when describing the pathophysiologv of gestational c. It should minimize or prevent the spread of infection D. Management principles are universal therefore one
b. she is expressing pressure diabetes? from individuals to families need not be concerned about people, culture, values,
c. the fetus utilizes her glucose stores and leaves her d. It should not overshadow concerns for the patient traditions and human relations.
with a Sow blood glucose a. Glucose levels decrease to accommodate fetal growth
d. of the rapid growth of the fetus b. Hypoinsulinemia develops early in the first trimester 73. Which among the following is important in the use a. B and C only
c. Pregnancy fosters the development of carbohydrate of the bag technique during home visit? b. A, B and D only
64. The nurse assesses the woman at 20 weeks cravings c. A and D only
gestation3 and expects the woman to report: d. There is progressive resistance to the effects of insulin a. Arrangement of the bag's contents must be d. B, A, and C only
convenient to the nurse
a. Spotting related to fetal implantation 69. When providing prenatal education to a pregnant b. The bag should contain all necessary supplies and 77. Management by Filipino values advocates the
b. Symptoms of diabetes as human placental lactogen is woman with asthma, which of the following would be equipment ready for use consideration of the Filipino goals trilogy according to
released important for the nurse to do? c. Be sure to thoroughly clean your bag especially when the Filipino priority-values which are:
c. Feeling fetal kicks exposed to communicable disease cases
d. Nausea and vomiting related HCG production a. Demonstrate how to assess her blood glucose d. Minimize if not totally prevent the spread of infection a. Family goals, national goals, organizational goals
b. Teach correct administration of subcutaneous b. Organizational goats, national goals, family goals
65. If Mrs. Medina comes to you for check-up on June 2, bronchodilators 74. This is an important procedure of the nurse during c. National goals, organizational goals, family goals
her EDO is June 11, what do you expect during c. Ensure she seeks treatment for any acute home visits? d. Family goals, organizational goals, national goals
assessment? exacerbation
d. Explain that she should avoid steroids during her a. protection of the CHN bag 78. Since the advocacy for the utilization of Filipino
a. Fundic ht 2 fingers below xyphoid process, engaged pregnancy b. arrangement of the contents of the CHM bag value-system in management has been encouraged, the
b. Cervix close, uneffaced, FH-midway between the c. cleaning of the CHN bag Nursing sector is no except, management needs to
umbilicus and symphysis pubis 70. Which of the following conditions would cause an d. proper handwashing examine Filipino values and discover its positive
c. Cervix open, fundic ht. 2 fingers below xyphoid insulin-dependent diabetic client the most difficulty potentials and harness them to achieve:
process, floating . during her pregnancy? 75. In consideration of the steps in applying the bag
d. Fundic height at least at the level of the xyphoid technique, which side of the paper lining of the CHN a. Employee satisfaction
process, engaged a. Rh incompatibility bag is considered clean to make a non-contaminated b. Organizational commits .ants, organizational
b. Placenta previa work area? objectives and employee satisfaction
Situation 14: - Please continue responding as a c. Hyperemesis gravidarum c. Employee objectives/satisfaction, commitments and
professional nurse in varied health situations through d. Abruption placentae a. The lower lip organizational objectives
the following questions. b. The outer surface d. Organizational objectives, commitments and
Situation 15 - One important toot a community health c. The upper lip employee objective/satisfaction
66. Which of the following medications would the nurse uses in the conduct of his/her activities is the CHN d. The inside surface
nurse expect the physician to order for recurrent Bag. Which of the following BEST DESCRIBES the use of 79. The following statements can correctly be made
convulsive seizures of a 10-year old child brought to this vital facility for our practice? Situation 16 - As a Community Health Nurse relating with about an effective and efficient community or even
your clinic? people in different communities, and in the agency managerial-leader.
71. The Community/Public Health Bag is: implementation of health programs and projects you A. Considers the achievement and advancement of the
a. Phenobarbital experience vividly as well the varying forms of leadership organization she/he represents as well as his people
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B. Considers the recognition of individual efforts toward wound healing a. Move him to the new bed before the baby arrives 93. An ear discharge that has been present for more
the realization of organizational goals as well as the d. A study examining client's feelings before, during and b. Explain that new sisters grow up to become best than 14 days can be classified as:
welfare of his people after a bone marrow aspiration friends
C. Considers the welfare of the organization above all c. Tell him he will have to share with the new baby a. mastoditis
other consideration by higher administration 83. Which of the following studies is based on d. Ask him to get his crib ready for the new baby b. chronic ear infection
D. Considers its own recognition by higher qualitative research? c. acute ear infection
administration for purposes of promotion and prestige 88. Ronnie's parents want to know how to react to him d. complicated ear infection
a. A study examining clients reactions to stress after when he begins to masturbate while watching
a. Only C and D are correct open heart surgery television. What would you suggest? 94. An ear discharge that has been present for jess than
b. A, C and D are correct b. A study measuring nutrition and weight, loss/gain in 14 days can be classified as:
c. B, C, and D are correct clients with cancer a. They refuse to allow him to watch television
d. Only A and B are correct c. A study examining oxygen levels after endotracheal b. They schedule a health check-up for sex-related a. chronic ear infection
suctioning disease b. mastoditis
80. Whether management at the community or agency d. A study measuring differences in blood pressure c. They remind him that some activities are private c. acute ear infection
level, there are 3 essential types of skills managers before during and after a procedure d. They give him "timeout" when this begins d. complicated ear infection
must have, these are:
A. Human relation skills, technical skills, and cognitive 84. An 85 year old client in a nursing home tells a nurse, 89. How many words does a typical 12-month-old 95. If the child has severe classification because of ear
skills "I signed the papers for that research study because the infant use? problem, what would be the best thing that you as the
B. Conceptual skills, human relation/behavioral skills, doctor was so insistent and I want: him to continue nurse can do?
and technical skills taking care of me." Which client right is being violated? a. About 12 words
C. Technical skills, budget and accounting skills, skills in b. Twenty or more words a. instruct mother when to return immediately
fund-raising a. Right of self determination c. About 50 words b. refer urgently
D. Manipulative skills, technical skills, resource b. Right to privacy and confidentiality d. Two, plus "mama" and "dada" c. give an antibiotic for 5 days
management skills c. Right to full disclosure d. dry the ear by wicking
d. Right not to be harmed 90. As a nurse. You reviewed infant safety procedures
a. A and D are correct with Bryan's mother. What are two of the most Situation 20 - If a child with diarrhea registers one sign in
b. B is correct 85. "A supposition or system of ideas that is proposed common types of accidents among infants? the pink row and one in the yellow; row in the IMCI
c. A is correct to explain a given phenomenon," best defines: Chart.
d. C and D are correct a. Aspiration and falls
a. a paradigm b. Falls and auto accidents 96. We can classify the patient as:
Situation 17 - You are actively practicing nurse who just b. a concept c. Poisoning and burns
finished your Graduate Studies. You earned the value of c. a theory d. Drowning and homicide a. moderate dehydration
Research and would like to utilize the knowledge and d. a conceptual framework b. some dehydration
skills gained in the application of research to Nursing Situation 19 - Among common conditions found in c. no dehydration
service. The following questions apply to research. Situation 18 - Nurse Michelle works with a Family children especially among poor communities are ear d. severe dehydration
Nursing Team in Calbayog Province specifically handling infection/problems. The following questions apply.
81. Which type of research Inquiry investigates the a UNICEF Project for Children. The following conditions 97. The child with no dehydration needs home
issue of human complexity (e.g. understanding the pertain, to CARE OP THE FAMILIES PRESCHOOLERS. 91. A child with ear problem should be assessed for the treatment Which of the following is not included the
human expertise) following EXCEPT: rules for home treatment in this case:
86. Ronnie asks constant questions. How many does a
a. Logical position typical 3-year-old ask in a day's time? a is there any fever? a. continue feeding the child
b. Naturalistic inquiry b. ear discharge b. give oresol every 4 hours
c. Positivism a. 1,200 or more c. if discharge is present for how long? c. know when to return to the health center
d. Quantitative Research b. Less than 50 d. ear pain d. give the child extra fluids
c. 100-200
82. Which of the following studies is based on d. 300-400 92. If the child does not have ear problem, using IMCI, 98. A child who has had diarrhea for 14 days but has no
quantitative research? what should you as the nurse do? sign of dehydration is classified as:
87. Ronnie will need to change to a new bed because
a. A study examining the bereavement process in his baby sister will need Ronnie's old crib. What a. Check for ear discharge a. severe persistent diarrhea
spouses of clients with terminal cancer measure would you suggest that his parents take to b. Check for tender swellings, behind the ear b. dysentery
b. A study exploring factors influencing weight control help decrease sibling rivalry between Ronnie and his c. Check for ear pain c. severe dysentery b. dysentery
behavior new sister? d. Go to the next question, check for malnutrition d. persistent diarrhea
c. A study measuring the effects of sleep deprivation on
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99. If the child has sunken eyes, drinking eagerly, 28. C 81. B
thirsty and skin pinch goes back slowly, the 29. B 82. C
classification would be: 30. D 83. A
31. B 84. A
a. no dehydration 32. B 85. C
b. moderate dehydration 33. D 86. D
c. some dehydration 34. D 87. A
d. severe dehydration 35. A 88. C
36. C 89. A
100. Carlo has had diarrhea for 5 days. There is no 37. C 90. A
blood in the stool, he is irritable. His eyes are sunken 38. A 91. A
the nurse offers fluid to Carlo and he drinks eagerly. 39. B 92. D
When the nurse pinched the abdomen, it goes back 40. C 93. B
slowly. How will you classify Carlo’s illness? 41. D 94. C
42. D 95. B
a. severe dehydration 43. B 96. D
b. no dehydration 44. D 97. B
c. some dehydration 45. B 98. D
d. moderate dehydration 46. B 99. C
47. D 100. C
48. C
49. A
50. C
ANSWER KEY: COMMUNITY HEALTH NURSING 51. C
AND CARE OF THE MOTHER AND CHILD 52. C
53. A
1. A 54. A
2. B 55. D
3. A 56. D
4. C 57. B
5. B 58. A
6. D 59. B
7. C 60.
8. D 61. A
9. A 62. B
10. B 63. D
11. D 64. C
12. D 65. A
13. A 66. A
14. B 67. C
15. A 68. D
16. C 69. C
17. D 70. C
18. A 71. B
19. B 72. A
20. D 73. D
21. C 74. D
22. C 75. B
23. A 76. D
24. C 77. D
25. A 78. D
26. B 79. D
27. A 80. C
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Comprehensive Exam 1 Fentanyl epidural analgesia is given. What is your record, disposal. You know that your institution is
a. Security Division nursing priority care in such a case? covered by this policy it;
Situation 1 - Concerted work efforts among members of b. Chaplaincy
the surgical team is essential to the success of the c. Social Service Section a. Instruct client to observe strict bed rest a. Your hospital is considered tertiary
surgical procedure. d. Pathology department b. Check for epidural catheter drainage b. Your hospital is in Metro Manila
c. Administer analgesia through epidural catheter as c. It obtained permit to operate from DOH
1. The sterile nurse or sterile personnel touch only Situation 2 - You are assigned in the Orthopedic Ward prescribed d. Your hospital is Philhealth accredited
sterile supplies and instruments. When there is a need where clients are complaining of pain in varying degrees d. Assess respiratory rate carefully
for sterile supply which is not in the sterile field, who upon movement of body parts. Situation 4 - In the OR, there are safety protocols that
hands out these items by opening its outer cover? Situation 3 - Records are vital tools in any institution and should be followed. The OR nurse should be well versed
6. Troy is a one day post open reduction and internal should be properly maintained for specific use and time. with all these to safeguard the safety and quality to
a. Circulating nurse fixation (ORIF) of the left hip and is in pain. Which of patient delivery outcome.
b. Anesthesiologist the following observation would prompt you to call the 11. The patient's medical record can work as a double-
c. Surgeon doctor? edged swords. When can the medical record become 16. Which of the following should be given highest
d. Nursing aide the doctor's/nurse worst enemy? priority when receiving patient in the OR?
a. Dressing is intact but partially soiled
2. The OR team performs distinct roles for one surgical b. Left foot is cold to touch and pedal pulse is absent a. When the record is voluminous a. Assess level of consciousness
procedure to be accomplished within a prescribed time c. Left leg in limited functional anatomic position b. When a medical record is subpoenaed in court b. Verify patient identification and informed consent
frame and deliver a standard patient outcome. White d. BP 114/78, pulse of 82 beats/minute c. When it is missing c. Assess vital signs
the surgeon performs the surgical procedure, who d. When the medical record is inaccurate, incomplete, d. Check for jewelry, gown, manicure and dentures
monitors the status of the client like urine output, 7. There is an order of Demerol 50 mg I.M. now and and inadequate
blood loss? every 6 hours p r n. You injected Demerol at 5 pm. The 17. Surgeries like I and D (incision and drainage) and
next dose of Demerol 50 mg I.M. is given: 12. Disposal of medical records in government debribement are relatively short procedures but
a. Scrub nurse hospitals/institutions must be done in close considered ‘dirty cases’. When are these; procedures
b. Surgeon a. When the client asks for the next dose coordination with what agency? best scheduled?
c. Anesthesiologist b. When the patient is in severe pain
d. Circulating nurse c. At 11pm a. Department of Interior and Local Government (DILG) a. Last case
d. At 12pm b. Metro Manila Development Authority (MMDA) b. In between cases
3. Surgery schedules are communicated to the OR c. Records Management Archives Office (RMAO) c. According to availability of anesthesiologist
usually a day prior to the procedure by the nurse of the 8. You continuously evaluate the client's adaptation to d. Depart of Health (DOH) d. According to the surgeon's preference
floor or ward where the patient is confined. For pain. Which of the following behaviors-indicate
orthopedic cases, what department is usually informed appropriate adaptation? 13. In the hospital, when you need-the medical record 18. OR nurses should be aware that maintaining the
to be present in the OR? of a discharged patient for research, you will request client's safety is the overall goal of nursing care during
a. The client reports pain reduction and decreased permission through: the intraoperative phase. As the circulating nurse, you
a. Rehabilitation department activity make certain that throughout the procedure...
b. Laboratory department b. The client denies existence of pain a. Doctor in charge
c. Maintenance department c. The client can distract himself during pain episodes b. The hospital director a. the surgeon greets his client before induction of
d. Radiology department d. The client reports independence from watchers c. The nursing Service anesthesia
d. Medical records section b. the surgeon and anestheriologist are in tandem
4. Minimally invasive surgery is very much into 9. Pain in Ortho cases may not be mainly due to the c. strap made of strong non-abrasive material are
technology. Aside from the usual surgical team who surgery. There might be other factors such as cultural 14. You readmitted a client who was in another fastened securely around the joints of the knees and
else to be present when a client undergoes or psychological that influence pain. How can you alter department a month ago. Since you will need the ankles and around the 2 hands around an arm board
laparoscopic surgery? these factors as the nurse? previous chart, from whom do you request the old d. client is monitored throughout the surgery by the
chart? assistant anesthesiologist
a. Information technician a. Explain all the possible interventions that may cause
b. Biomedical technician the client to worry. a. Central supply section 19. Another nursing check that should not be missed
c. Electrician b. Establish trusting relationship by giving his medication b. Previous doctor's clinic before the induction of general anesthesia is:
d. Laboratory technicial on time c. Department where the patient was previously
c. Stay with the client during pain episodes admitted a. check for presence underwear
5. In massive blood loss, prompt replacement of d. Promote client's sense of control and participation in d. Medical records section b. check for presence dentures
compatible blood is crucial. What department needs to pain control by listening to his concerns c. check patient's
be alerted to coordinate closely with the patient's 15. Records Management and Archives Offices of the d. check baseline vital signs
family for immediate blood component therapy? 10. In some hip surgeries, an epidural catheter for DOH is responsible for implementing its policies on
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20. Some different habits and hobbies affect 25. Which of the following nursing intervention is done a. metabolic alkalosis Incident Report (IR)
postoperative respiratory function. If your client when examining the incision wound and changing the b. respiratory acidosis c. Allow client to walk with relative to the OF?
smokes 3 packs of cigarettes a day for the part 10 years, dressing? c. respiratory alkalosis d. Assess and periodically reassess individual client's risk
you will anticipate increased risk for: d. metabolic acidosis for falling
a. Observe the dressing and type and odor of drainage if
a. perioperative anxiety and stress any Situation 7 - Joint Commission on Accreditation of 35. As a nurse you know you can improve on accuracy
b. delayed coagulation time b. Get patient's consent Hospital Organization (JCAHP) patient safety goals and of patient's identification by 2 patient identifiers,
c. delayed wound healing c. Wash hands requirements include the care and efficient use of EXCEPT:
d. postoperative respiratory function d. Request the client to expose the incision wound technology in the OR arid elsewhere in the healthcare
facility. a. identify the client by his/her wrist tag and verify with
Situation 5 - Nurses hold a variety of roles when Situation 6 - Carlo, 16 years old, comes to the ER with family members
providing care to a perioperative patient. acute asthmatic attack. RR is 46/min and he appears to 31. As the head nurse in the OR, how can you improve b. identify client by his/her wrist tag and call his/her by
be in acute respiratory distress. the effectiveness of clinical alarm systems? name
21. Which of the following role would be the c. call the client by his/her case and bed number
responsibility of the scrub nurse? 26. Which of She following nursing actions should be a. limit suppliers to a few so that quality is maintained d. call the patient by his/her name and bed number
initiated first? b. implement a regular inventory of supplies and
a. Assess the readiness of the client prior to surgery equipment Situation 8 - Team efforts is best demonstrated in the OR
b. Ensure that the airway is adequate a. Promote emotional support c. Adherence to manufacturer's recommendation
c. Account for the number of sponges, needles, supplies, b. Administer oxygen at 6L/min d. Implement a regular maintenance and testing of alarm 36. If you are the nurse in charge for scheduling surgical
Used during the surgical procedure c. Suction the client every 30 min systems cases, what important information do you need to ask
d. Evaluate the type of anesthesia appropriate for the d. Administer bronchodilator by nebulizer the surgeon?
surgical client 32. Over dosage of medication or anesthetic can
27. Aminophylline was ordered for acute asthmatic happen even with the aid of technology like infusion a. Who is your internist
22. As a perioperative nurse, how can you best meet attack. The mother asked the nurse, what its indication pump, sphymomanometer, and similar b. Who is your assistant and anesthesiologist, and what
the safety need of the client after administering the nurse will say is: devices/machines. As a staff, how can you improve the is your preferred time and type of surgery?
preoperative narcotic? safety of using infusion pumps? c. Who are your anesthesiologist, internist, and assistant
a. Relax smooth muscles of the bronchial airway d. Who is your anesthesiologist.
a. Put side rails up and ask client not to get out of bed b. Promote expectoration a. Check the functionality of the pump before use
b. Send the client to ORD with the family c. Prevent thickening of secretions b. Select your brand of infusion pump like you do with 37. In the OR, the nursing tandem for every surgery is:
c. Allow client to get up to go to the comfort room d. Suppress cough your cellphone
d. Obtain consent form C. Allow the technician to set the; infusion pump before a. Instrument technician and circulating nurse
28. You will give health instructions to Carlo, a case of use b. Nurse anesthetist, nurse assistant, and instrument
23. It is the responsibility of the pre-op, nurse to do bronchial asthma. The health instruction will include d. Verify the flow rate against your computation technician
skin prep for patients undergoing surgery. If hair at the the following EXCEPT: c. Scrub nurse and nurse anesthetist
operative site is not shaved, what should be done to 33. JCAHOs universal protocol for surgical and invasive d. Scrub and circulating nurses
make suturing easy and lessen chance of incision a. Avoid emotional stress and extreme temperature procedures to prevent wrong site, wrong person, and
infection? b. Avoid pollution like smoking wrong procedures/surgery includes the following 38. While team effort is needed in the OR for efficient
c. Avoid pollens, dust seafood EXCEPT: and quality patient care delivery, we should limit the
a. Draped d. Practice respiratory isolation number of people in the room for infection control.
b. Pulled a. Mark the operative site if possible Who comprise this team?
c. Clipped 29. The asthmatic client asked you what breathing b. Conduct pre-procedure verification process
d. Shampooed technique he can best practice when asthmatic attack c. Take a video of the entire intra-operative procedure a. Surgeon, anesthesiologist, scrub nurse, radiologist,
starts. What will be the best position? d. Conduct time out immediately before starting the orderly
24. It is also the nurse's function to determine when procedure b. Surgeon, assistants, scrub nurse, circulating nurse,
infection is developing in the surgical incision. The a. Sit in high-Fowler's position with extended legs anesthesiologist
perioperative nurse should observe for what signs of b. Sit-up with shoulders back 34. You identified a potential risk of pre and post c. Surgeon, assistant surgeon, anesthesiologist, scrub
impending infection? c. Push on abdomen during exhalation operative clients. To reduce the risk of patient harm nurse, pathologist
d. Lean forward 30-40 degrees with each exhalation resulting from fall, you can implement the following d. Surgeon, assistant surgeon, anesthesiologist, intern,
a. Localized heat and redness EXCEPT: scrub nurse
b. Serosanguinous exudates and skin blanching 30. As a nurse you are always alerted to monitor status
c. Separation of the incision asthmaticus who will likely and initially manifest a. Assess potential risk of fail associated with the 39. When surgery is on-going, who coordinates the
d. Blood clots and scar tissue are visible symptoms of: patient's the following EXCEPT: medication regimen activities outside, including the family?
b. Take action to address any identified risks through
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a. Orderly/clerk should be drained? and scrub nurses have critical responsibility about confidence?
b. Nurse supervisor sponge and Instrument count.
c. Circulating nurse a. Sensation of taste a. Patient's advocate
d. Anaesthesiologist b. Sensation of pressure 51. When is the first sponge/instrument count b. Educator
c. Sensation of smell reported? c. Patient's Liaison
40. The breakdown in teamwork is often times a failure d. Urge to defecate d. Patient's arbiter
in: a. Before closing the subcutaneous layer
Situation 10 - As a beginner in research, you are aware b. Before peritoneum is closed 57. As a nurse, you can help improve the effectiveness
a. Electricity that sampling is an essential element of the research c. Before dosing the skin of communication among healthcare givers
b. Inadequate supply process. d. Before the fascia is sutured
c. Leg work a. Use of reminders of what to do
d. Communication 46. What does a sample group represent? 52. What major supportive layer of the abdominal wall b. Using standardized list of abbreviations, acronyms,
must be sutured with long tensile strength such as and symbols
Situation 9 - Colostomy is a surgically created anus- It a. Control group cotton or nylon or silk suture? c. One-on-one oral endorsement
can be temporary or permanent, depending on the b. Study subjects d. Text messaging and e-mail
disease condition. c. General population a. Fascia
d. Universe b. Muscle 58. As a nurse, your primary focus in the workplace is
41. Skin care around the stoma is critical. Which of the c. Peritoneum the client's safety. However, personal safety is also a
following is not indicated as a skin care barriers? 47. What is the most important characteristics of a d. Skin concern. You can communicate hazards to your co-
a. Apply liberal amount of mineral oil to the area sample? workers through the use of the following EXCEPT:
b. Use karaya paste and rings around the stoma 53. Like sutures, needles also vary in shape and uses. If
c. Clean the area daily with soap and water before a. Randomization you are the scrub nurse for a patient who is prone to a. Formal training
applying bag b. Appropriate location keloid formation and has a low threshold of pain, what b. Posters
d. Apply talcum powder twice a day c. Appropriate number needle would you prepare? c. Posting IR in the bulletin board
d. Representativeness d. Use of labels and signs
42. What health instruction will enhance regulation of a a. Round needle
colostomy (defecation) of clients? 48. Random sampling ensures that each subject has: b. A traumatic needle 59. As a nurse, what is one of the best way to reconcile
c. Reverse cutting needle medications across the continuum of care?
a. Irrigate after lunch everyday a. Been selected systematically d. Tapered needle
b. Eat fruits and vegetables in all three meals b. An equal change of selection a. Endorse on a case-to-case basis
c. Eat balanced meals at regular intervals c. Been selected based on set criteria 54. Another alternative "suture" for skin closure is the b. Communication a complete list of the patient's
d. Restrict exercise to walking only d. Characteristics that match other samples use of _______________: medication to the next provider of service
c. Endorse in writing
43. After ileostomy, which of the following condition is 49. Which of the following sampling methods allows a. Staple d. Endorse the routine and 'stat' medications every shift
NOT expected? the use of any group of research subject? b. Therapeutic glue
c. Absorbent dressing 60. As a nurse, you protect yourself and co-workers
a. increased weight a. Purposive d. invisible suture from misinformation and misrepresentations through
b. Irritation of skin around the stoma b. Convenience the following EXCEPT:
c. Liquid stool c. Snow-bail 55. Like any nursing interventions, counts should be
d. Establishment of regular bowel movement d. Quota documented. To whom does the scrub nurse report any a. Provide information to clients about a variety of
discrepancy of country so that immediate 'and services that can help alleviate the client's pain and
44. The following are appropriate nursing interventions 50. You decided to include 5 barangays in your appropriate action in instituted? other conditions
during colostomy irrigation EXCEPT: municipality and chose a sampling method that would b. Advising the client, by virtue of your expertise, that
get representative samples from each barangay. What a. Anesthesiologist which can contribute to the client's well-being
a. Increase the irrigating solution flow rate when should be the appropriate method for you to use in this b. Surgeon c. Health education among clients and significant others
abdominal cramps is felt care? c. Or nurse supervisor regarding the use of chemical disinfectant
b. Insert 2-4 inches of an adequately lubricated catheter d. Circulating nurse d. Endorsement thru trimedia to advertise your favorite
to the stoma a. Cluster sampling disinfectant solution
c. Position client in semi-Fowler b. Random sampling Situation 12 - As a nurse, you should be aware and
d. Hand the solution 18 inches above the stoma c. Stratifies sampling prepared of the different roles you play. 61. A one-day postoperative abdominal surgery client
d. Systematic sampling has been complaining of severe throbbing abdominal
45. What sensation is used as a gauge so that patients 56. What role do you play, when you hold all clients’ pain described as 9 in a 1-10 pain rating. Your
with ileostomy can determine how often their pouch Situation 11 -After an abdominal surgery, the circulating information entrusted to you in the strictest assessment reveals bowel sounds on all quadrants and
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the dressing is dry and intact. What nursing the nurse to any of the following positions, EXCEPT:
intervention would you take? 67. As the nurse, you should anticipate to administer a. Gown
which of the following medications to Zeny who is a. straddling a chair with arms and head resting on the b. Eyewear
a. Medicate client as prescribed diagnosed to be suffering from hypothyroidism? back of the chair c. Face mask
b. Encourage client to do imagery b. lying on the unaffected side with the bed elevated 30- d. Gloves
c. Encourage deep breathing and turning a. Levothyroxine 40 degrees
d. Call surgeon stat b. Lidocaine c. lying prone with the head of the bed lowered 15-30 78. What will you do to ensure that Kyle, who is febrile,
c. Lipitor degrees will have a liberal oral fluid intake?
62. Pentoxicodone 5 mg IV every 8 hours was d. Levophed d. sitting on the edge of the bed with her feet supported
prescribed for post abdominal pain. Which will be your and arms and head on a padded overhead table a. Provide a glass of fruit every meal
priority nursing action? 68. Your appropriate nursing diagnosis for Zeny who is b. Regulate his IV to 30 drops per minute
suffering from hypothyroidism would probably include 73. During thoracentesis, which of the following nursing c. Provide a calibrated pitcher of drinking water and juice
a. Check abdominal dressing for possible swelling which of the following? intervention will be most crucial? at the bedside and monitor intake and output
b. Explain the proper use of PCA to alleviate anxiety d. Provide a writing pad to record his intake
c. Avoid overdosing to prevent dependence/tolerance a. Activity intolerance related to tiredness associated a. Place patient in a quiet and cool room
d. Monitor VS, more importantly RR . with disorder b. Maintain strict aseptic technique 79. Before bedtime, you went to ensure Kyle's safety in
b. Risk to injury related to incomplete eyelid closure c. Advice patient to sit perfectly still during needle 'bed. You will do which of the following:
63. The client complained of abdominal and pain. Your c. Imbalance nutrition related to hypermetabolism insertion until it has been withdrawn from the chest
nursing intervention that can alleviate pain is: d. Deficient fluid volume related to diarrhea d. Apply pressure over the puncture site as soon as the a. Put the lights on
needle is withdrawn b. Put the side rails up
a. Instruct client to go to sleep and relax 69. Myxedema coma is a life threatening complication c. Test the call system
b. Advice the client to close the lips and avoid deep of long standing and untreated hypothyroidism with 74. To prevent leakage of fluid in the thoracic cavity, d. Lock the doors
breathing and talking one of the following characteristics. how wilt you position the client after thoracentesis?
c. Offer hot and clear soup 80. Kyle's room is fully mechanized. What do you teach
d. Turn to sides frequently and avoid too much talking a. Hyperglycemia a. Place flat in bed the watcher and Kyle to alert the nurse for help?
b. hypothermia b. Turn on the unaffected side
64. Surgical pain might be minimized by which nursing c. hyperthermia c. Turn on the affected side a. How to lock side rails
action in the OR: d. hypoglycemia d. On bed rest b. Number of the telephone operator
c. Call system
a. Skill of surgical team and lesser manipulation 70. As a nurse, you know that the most common type 75. Chest x-ray was ordered after thoracentesis. When d. Remote control
b. Appropriate preparation For the scheduled procedure of goiter is related to a deficiency you client asks what is the reason for another chest x-
c. Use of modem technology in closing the wound ray, you will explain: Situation 17 - Tony, 11 years old, has 'kissing tonsils' and
d. Proper positioning and draping of clients a. thyroxine is scheduled for tonsillectomy and adenoidectomy or T
b. thyrotropin a. to rule out pneumothorax and A.
65. One very common cause of postoperative pain is: c. iron b. to rule out any possible perforation
d. iodine c. to decongest 81. You are the nurse of Tony who will undergo T and A
a. Forceful traction during surgery d. to rule out any foreign: body in the morning. His mother asked you if Tony will be
b. Prolonged surgery Situation 15 - Mrs. Pichay is admitted to your ward. The put to sleep. Your teaching will focus on:
c. Break in aseptic technique MD ordered "Prepared for thoracentesis this pm to Situation 16 - In the hospital, you are aware that we are
d. Inadequate anesthetic remove excess air from the pleural cavity." helped by the .use of a variety of equipment/devices to a. spinal anesthesia
enhance quality patient care delivery; b. anesthesiologist’s preference
Situation 14 - You were on duty at the medical ward 71. Which of the following nursing responsibility is c. local anesthesia
when Zeny came in for admission for tiredness, cold essential in Mrs. Pichay who will undergo 76. You are initiate an IV line to your patient, Kyle, 5, d. general anesthesia
intolerance, constipation, and weight gain. Upon thoracentesis? who is febrile. What IV administration set will you
examination, the doctor's diagnosis was hypothyroidism. prepare? 82. Mothers of children undergoing tonsillectomy and
a. Support, and reassure client during the procedure adenoidectomy usually ask what food prepared and
66. Your independent nursing care for hypothyroidism b. Ensure that informed consent has been signed a. Blood transfusion set give their children after surgery. You as the nurse will
includes: c. Determine if client has allergic reaction to local b. Macroset say:
anesthesia c. Volumetric chamber
a. administer sedative round the clock d. Ascertain if chest x-rays and other tests have been d. Microset a. balanced diet when fully awake
b. administer thyroid hormone replacement prescribed and completed b. hot soup when awake
c. providing a cool, quiet, and comfortable environment 77. Kyle is diagnosed to have measles. What will your c. ice cream when fully awake
d. encourage to drink 6-8 glasses of water 72. Mrs. Pichay who is for thoracentesis is assisted by protective personal attire include? d. soft diet when fully awake
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d. Bananas, cantaloupe, orange and other fresh fruits a. Report signs and symptoms for delayed allergic
83. The RR nurse should monitor for the most common can be included in the diet reactions a. Administer by fast drip
postoperative complication of: b. Observe NPO for 6 hours b. Inject the drugs as close to the IV injection site
88. Rudy undergoes hemodialysis for the first time and c. Increase fluid intake c. Incorporate to the IV solution
a. hemorrhage was scared of disequilibrium syndrome. He asked you d. Monitor intake and output d. Use volumetric chamber
b. endotracheal tube perforation how this can be prevented. Your response is:
c. esopharyngeal edema 93. Post IVP, Fe should excrete the contrast medium. 98. One patient has a 'runaway' IV of 50% dextrose. To
d. epiglottis a. maintain a conducive comfortable and cool You instructed the family to include more vegetables in prevent temporary excess of insulin transient
environment the diet and hyperinsulin reaction, what solution should you
84. The PACU nurse will maintain postoperative T and A b. maintain fluid and electrolyte balance prepare in anticipation of the doctors order?
client in what position? c. initial hemodialysis shall be done for 30 minutes only a. increase fluid intake
so as not to rapidly remove the waste from the blood b. barium enema a. Any IV solution available to KVO
a. Supine with neck hyperextended and supported with than from the brain c. cleansing enema b. Isotonic solution
pillow d. maintain aseptic technique throughout the d. gastric lavage c. Hypertonic solution
b. Prone with the head on pillow and tuned to the side hemodialysis d. Hypotonic solution
c. Semi-Fowler's with neck flexed 94. The IVP reveals that Fe has small renal calculus that
d. Reverse trendelenburg with extended neck 89. You are assisted by a nursing aide with the care of can be passed out spontaneously. To increase the 99. How can nurse prevent drug interaction including
the client with renal failure. Which delegated function chance of passing the stones, you instructed her to absorption?
85. Tony is to be discharged in the afternoon of the to the aide would you particularly check? force fluids and do which of the following?
same day after tonsillectomy and adenoidectomy. You a. Always flush with NSS after IV administration
as the RN will make sure that the family knows to: a. Monitoring and recording I and O a. Balanced diet b. Administering drugs with more diluents
b. Checking bowel movement b. Ambulance more c. Improving on preparation techniques
a. offer osteorized feeding c. Obtaining vital signs c. Strain all urine d. Referring to manufacturer's guidelines
b. offer soft foods for a week to minimize discomfort d. Monitoring diet d. Bed rest
while swallowing 100. In insulin administration, it should be understood
c. supplement his diet with vitamin C rich juices to 90. A renal failure patient was ordered for creatinine 95. The presence of calculi in the urinary tract is called: that our body normally releases insulin according to our
enhance heating clearance. As the nurse you will collect blood glucose level. When is insulin and glucose level
d. offer clear liquid for 3 days to prevent irritation a. Colelithiasis highest?
a. 48 jour urine specimen b. Nephrolithiasis
Situation 18 - Rudy was diagnosed to have chronic renal b. first morning urine c. Ureterolithiasis a. After excitement
failure. Hemodialysis is ordered that an A-V shunt was c. 24 hour urine specimen d. Urolithiasis b. After a good night's rest
surgically created. d. random urine specimen c. After an exercise
Situation 20 - At the medical-surgical ward, the nurse d. After ingestion of food
86. Which of the following action would be of highest Situation 19 - Fe is experiencing left sharp pain and must also be concerned about drug interactions.
priority with regards to the external shunt? occasional hematuria. She was advised to undergo IVP
by her physician. 96. You have a client with TPN. You know that in TPN, CARE OF CLIENTS WITH PHYSIOLOGIC AND
a. Avoid taking BP or blood sample from the arm with like blood transfusion, there should be no drug PSYCHOSOCIAL ALTERATIONS
shunt 91. Fe was so anxious about the procedure and incorporation. However, the MD's order read;
b. Instruct the client not to exercise the arm with the particularly expressed her low pain threshold. Nursing incorporate insulin to present TPN. Will you follow the Situation 1 - Because of the serious consequences of
shunt health instruction will include: order? severe burns management requires a multi disciplinary
c. Heparinize the shunt daily approach. You have important responsibilities as a
d. Change dressing of the shunt daily a. assure the client that the pain is associated with the a. No, because insulin will induce hyperglycemia in nurse.
warm sensation during the administration of the patients with TPN
87. Diet therapy for Rudy, who has acute renal failure, Hypaque by IV b. Yes, because insulin is chemically stable with TPN and 1. While Sergio was lighting a barbecue grill with a
is tow-protein, low potassium and sodium. The b. assure the client that the procedure painless can enhance blood glucose level lighter fluid, his shirt burst into flames. The most
nutrition instruction should include: c. assure the client that contrast medium will be given c. No, because insulin is not compatible with TPN effective way to extinguish the flames with as little
orally d. Yes, because it was ordered by the MD further damage as possible is to:
a. Recommend protein of high biologic value like eggs, d. assure the client that x-ray procedure like IVP is only
poultry and lean meat done by experts 97. The RN should also know that some drugs have a. log roll on the grass/ground
b. Encourage client to include raw cucumbers, carrot, increased absorption when infused in PVC container. b. slap the flames with his hands
cabbage, and tomatoes 92. What will the nurse monitor and instruct the client How will you administer drugs such as insulin, c. remove the burning clothes
c. Allowing the client cheese, canned foods, and other and significant others, post IVP? nitroglycerine hydralazine to promote better d. pour cold liquid over the flames
processed food therapeutic drug effects?
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2. Once the flames are extinguished, it is most b. Call security officer and report the incident this type of cancer. b. Fermin can lie on the side comfortably, about the 3rd
important to: c. Call your nurse supervisor and report the incident : postoperative day
d. Call the physician on duty 11. Larry, 55 years old, who is suspected of having c. The abdominal incision is close and contamination is
a. cover Sergio with a warm blanket colorectal cancer, is admitted to the CI. After taking the no longer a danger
b. give him sips of water 7. You are on morning duty in the medical ward. You history and vital signs the physician does which test as d. The stool starts to become formed, around the 7th
c. calculate the extent of his burns have 10 patients assigned to you. During your a screening test for colorectal cancer. postoperative day
d. assess the Sergio's breathing endorsement rounds, you found out that one of your
patients was not in bed. The patient next to him a. Barium enema 17. When preparing to teach Fermin how to irrigate his
3. Sergio is brought to the Emergency Room after the informed you that he went home without notifying the b. Carcinoembryonig antigen colostomy, you should plan to do the procedure:
barbecue grill accident. Based on the assessment of the nurses. Which among the following will you do first? c. Annual digital rectal examination
physician, Sergio sustained superficial partial thickness d. Proctosigmoidoscopy a. When Fermin would have normal bowel movement
bums on his trunk, right upper extremities ad right a. Make and incident report b. At least 2 hours before visiting hours
lower extremities. His wife asks what that means. Your b. Call security to report the incident 12. To confirm his impression of colorectal cancer, Larry c. Prior to breakfast and morning care
most accurate response would be: c. Wait for 2 hours before reporting will require which diagnostic study? d. After Fermin accepts alteration in body image
d. Report the incident to your supervisor
a. Structures beneath the skin are damaged a. carcinoembryonic antigen 18. When observing a rectum demonstration of
b. Dermis is partially damaged 8. You are on duty in the medical ward. You were asked b. proctosigmoidbscopy colostomy irrigation, you know that more teaching is
c. Epidermis and dermis are both damaged to check the narcotics cabinet. You found out that what c. stool hematologic test required if Fermin:
d. Epidermis is damaged is on record does not tally with the drugs used. Which d. abdominal computed tomography (CT) test
among the following will you do first? a. Lubricates the tip of the catheter prior to inserting
4. During the first 24 hours after thermal injury, you 13. The following are risk factors for colorectal cancer, into the stoma
should assess Sergio for a. Write an incident report and refer the matter to the EXCEPT: b. Hands the irrigating bag on the bathroom door doth
nursing director hook during fluid insertion
a. hypokalemia and hypernatremia b. Keep your findings to yourself a. inflammatory bowels c. Discontinues the insertion of fluid after only 500 ml of
b. hypokalemia and hyponatremia c. Report the matter to your supervisor b. high fat, high fiver diet fluid had been insertion
c. hyperkalemia and hyponatremia d. Find out from the endorsement any patient who c. smoking d. Clamps off the flow of fluid when feeling
d. hyperkalemia and hypernatremia might have been given narcotics d. genetic factors-familial adenomatous polyposis uncomfortable
5. Teddy, who sustained deep partial thickness and full 9. You are on duty in the medical ward. The mother of 14. Symptoms associated with cancer of the colon 19. You are aware that teaching about colostomy care
thickness burns of the face, whole anterior chest and your patient who is also a nurse came running to the include: is understood when Fermin states, "I will contact my
both upper extremities two days ago, begins to exhibit nurse station and informed you that Fiolo went into physician and report:
extreme restlessness. You recognize that this most cardiopulmonary arrest. Which among the following a. constipation, ascites and mucus in the stool
likely indicates that Teddy is developing: will you do first? b. diarrhea, heartburn and eructation a. If I have any difficulty inserting the irrigating tub into
c. blood in the stools, anemia, and pencil-shaped, stools the stoma.”
a. Cerebral hypoxia a. Start basic life support measures d. anorexia, hematemesis, and increased peristalsis b. If I notice a loss of sensation to touch in the stoma
b. Hypervolemia b. Call for the Code tissue."
c. Metabolic acidosis c. Bring the crush cart to the room 15. Several days prior to bowel surgery, Larry may be c. The expulsion of flatus while the irrigating fluid is
d. Renal failure . d. Go to see Fiolo and assess for airway patency and given sulfasuxidine and neomycin primarily to: running out."
breathing problems d. When mucus is passed from the stoma between
Situation 2 - You are now working as a staff nurse in a a. promote rest of the bowel by minimizing peristalsis irrigation."
general hospital. You have to be prepared to handle 10. You are admitting Jorge to the ward and you found b. reduce the bacterial content of the colon
situations with ethico-legal and moral implications. out that he is positive for HIV. Which among the c. empty the bowel of solid waste 20. You would know after teaching. Fermin that dietary
following will you do first? d. soften the stool by retaining water in the colon instruction for him is effective when he states, "It is
6. You are on night duty in the surgical ward. One of important that I eat:
our patients Martin is prisoner who sustained an a. Take note of it and plan to endorse this to next shift Situation 4 - ENTEROSTOMAL THERAPY is now
abdominal gunshot wound. He is being guarded by b. Keep this matter to your self considered especially in nursing. You are participating in a. Soft foods that are easily digested and absorbed by my
policemen from the local police unit. During your c. Write an incident report the OSTOMY CARE CLASS. large intestine."
rounds you heard a commotion. You saw the policeman d. Report the matter to your head nurse b. Bland food so that my intestines do not become
trying to hit Martin. You asked why he was trying to 16. You plan to teach Fermin how to irrigate the irritate."
hurt Martin. He denied the matter. Which among the Situation 3 - Colorectal cancer can affect old and colostomy when: c. Food low in fiber so that there is less stool."
following activities will you do first? younger people. Surgical procedures and other modes of d. Everything that I ate before the operation, while
treatment are done to ensure quality of life. You are a. The perineal wound heals and Fermin can sit avoiding foods that cause gas."
a. Write an incident report assigned in the Cancer institute to care of patients with comfortably on the commode
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Situation 5 - Ensuring safety is one of your most are favorable. Infection control is one important d. Gram stain testing c. is permanently paralyzed
important responsibilities. You will need to provide responsibility of the nurse to ensure quality of care. d. has received a significant brain injury
instructions and information to your clients to prevent Situation 7 - As a nurse you need to anticipate the
complications. 26. Honrad, who has been complaining of anorexia and occurrence of complications of stroke so that life Situation 8 - With the improvement in life expectancies
feeling tired, develops jaundice. After a workup he is threatening situations can be prevented. and the emphasis in the quality of life it is important to
21. Randy has chest tubes attached to a pleural diagnosed of having Hepatitis A. His wife asks you provide quality care to our older patients. There are
drainage system. When caring for him you should: about gamma globulin for herself and her household 31. Wendy is admitted to the hospital with signs and frequently encountered situations and issues relevant to
help. Your most appropriate response would be: symptoms of stroke. Her Glasgow Coma Scale is 6 on the older, patients.
a. empty the drainage system at the end of the shift admission. A central venous catheter was inserted and
b. clamp the chest tube when auctioning a. "Don't worry your husband's type of hepatitis is no an I.V. infusion was started. As a nurse assigned to 36. Hypoxia may occur in the older patients because of
c. palpate the surrounding areas for crepitus longer communicable" Wendy what will he your priority goal? which of the following physiologic changer associated
d. change the dressing daily using aseptic techniques b. "Gamma globulin provides passive immunity for with aging.
Hepatitis B" a. Prevent skin breakdown
22. Fanny came in from PACU after pelvic surgery. As c. "You should contact your physician immediately about b. Preserve muscle function a Ineffective airway clearance
Fanny's nurse you know that the sign that would be getting gamma globulin." c. Promote urinary elimination b. Decreased alveolar surface area
indicative of a developing thrombophlebitis would be: d. "A vaccine has been developed for this type of d. Maintain a patent airway c. Decreased anterior-posterior chest diameter
hepatitis" d. Hyperventilation
a. a tender, painful area on the leg 32. Knowing that for a comatose patient hearing is the
b. a pitting edema of the ankle 27. Voltaire develops a nosocomial respiratory tract best last sense to be lost, as Judy's nurse, what should 37. The older patient is at higher risk for in
c. a reddened area at the ankle infection. He asks you what that means. you do? inconvenience because of:
d. pruritus on the calf and ankle
a. "You acquired the infection after you have been a. Tell her family that probably she can't hear them a. dilated urethra
23. To prevent recurrent attacks on Terry who has admitted to the hospital." b. Talk loudly so that Wendy can hear you b. increased glomerular filtration rate
acute glumerulonephritis, you should instruct her to: b. "This is a highly contagious infection requiring c. Tell her family who are in the room not to talk c. diuretic use
complete isolation." d. Speak softly then hold her hands gently d. decreased bladder capacity
a. seek early treatment for respiratory infections c. "The infection you had prior to hospitalization flared
b. take showers instead of tub bath up." 33. Which among the following interventions should 38. Merle, age 86, is complaining of dizziness when she
c. continue to take the same restrictions on fluid intake d. "As a result of medical treatment, you have acquired a you consider as the highest priority when caring for stands up. This may indicate:
d. avoid situations that involve physical activity secondary infection.'' June who has hemiparersis secondary to stroke?
a. dementia
24. Herbert has a laryngectomy and he is now for 28. As a nurse you know that one of the complications a. Place June on an upright lateral position b. a visual problem
discharge. Re verbalized his concern regarding his that you have to watch out for when caring for Omar b. Perform range of motion exercises c. functional decline
laryngectomy tube being dislodged. What should you who is receiving total parenteral nutrition is: c. Apply antiembolic stocking d. drug toxicity
teach him first? d. Use hand rolls or pillows for support
a. stomatitis 39. Cardiac ischemia in an older patient usually
a. Recognize that prompt closure of the tracheal opening b. hepatitis 34. Ivy, age 40, was admitted to the hospital with a produces:
may occur c. dysrhythmia severe headache, stiff neck and photophobia. She was
b. Keep calm because there is no immediate emergency d. infection diagnosed with a subarachnoid hemorrhage secondary a. ST-T wave changes
c. Reinsert another tubing immediately to ruptured aneurysm. While waiting for surgery, you b. Very high creatinine kinase level
d. Notify the physician at once 29. A solution used to treat Pseudomonas would can provide a therapeutic by doing which of the c. chest pain radiating to the left arm
infection is: following? d. acute confusion
25. When caring for Larry after an exploratory chest
surgery and pneumonectomy, your priority would be to a. Dakin's solution a. honoring her request for a television 40. The most dependable sign of infection in the older
maintain: b. Half-strength hydrogen peroxide b. placing her bed near the window patient is:
b. Acetic acid c. dimming the light in her room
a. supplementary oxygen d. Betadine d. allowing the family unrestricted visiting privileges a. change in mental status pain
b. ventilation exchange b. fever
c. chest tube drainage 30. Which of the following is most reliable in diagnosing 35. When performing a neurological assessment on c. pain
d. blood replacement a wound infection? Walter, you find that his pupils are fixed and dilated. d. decreased breath sound with crackles
This indicated that he:
Situation 6 - Infection can cause debilitating a. Culture and sensitivity Situation 9 - A "disaster" is a large-scale emergency—
consequences when host resistance is compromised and b. Purulent drainage from a wound a. probably has meningitis even a small emergency left unmanaged may turn into a
virulence of microorganisms and environmental factors c. WBC count of 20,000/pL b. is going to be blind because of trauma disaster. Disaster preparedness is crucial and is
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everybody's business. There are agencies that are in d. Urgent reason for the referral help her by:
charge of ensuring prompt response. Comprehensive c. Determine their learning needs then prioritize
Emergency Management (CEM) is an integrated 45. Which of the following terms refer to a process by d. involve the whole family in the teaching class a. Coming back periodically and indicating your
approach to the management of emergency program which the individual receives education about availability if she would like you to sit with her
and activities for all four emergency phases (mitigation, recognition of stress reactions and management 49. You have been designated as a member of the task b. Insisting that Ruby should talk with you because it is
preparedness, response, and recovery), for all type of strategies for handling stress which may be instituted force to plan activities for the Cancer Consciousness not good to Keep everything inside
emergencies and disasters (natural, man-made, and after a disaster? Week. Your committee has 4 months to plan and c. Leaving her atone because she is uncooperative and
attack) and for all levels of government and the private implement the plan. You are assigned to contact the unpleasant to be with
sector. a. Critical incident stress management various cancer support groups in your hospital. What d. Encouraging her to be physically active as possible
b. Follow-up will be your priority activity?
41. Which of the four phases of emergency c. Defriefing 53. Leo who is terminally ill and recognizes that he is in
management is defined as "sustained action that d. Defusion a. Find out if there is a budget for this activity the process of losing, everything and everybody he
reduces or eliminates long-term risk to people and b. Clarify objectives of the activity with the task force loves, is depressed. Which of the following would best
properly from natural hazards and the effect"? Situation 10 - As a member of the health and nursing before contacting the support groups help him during depression?
team you have a crucial role to play in ensuring that all c. Determine the VIPs and Celebrities who will be invited
a. Recovery the members participate actively is the various tasks d. Find out how many support groups there are in the a. Arrange for visitors who might cheer him
b. Mitigation agreed upon, hospital and get the contact number of their president b. Sit down and talk with him for a while
c. Response c. Encourage him to look at the brighter side of things
d. Preparedness 46. While eating his meal, Matthew accidentally 50. You are invited to participate in the medical mission d. Sit silently with him
dislodges his IV line and bleeds. Blood oozes on the activity of your alumni association. In the planning
42. You are a community health nurse collaborating surface of the over-bed table. It is most appropriate stage everybody is expected to identify what they can 54. Which of the following statements would best
with the Red Cross and working with disaster relief that you instruct the housekeeper to clean the table do during the medical mission and what resources are indicate that Ruffy; who is dying has accepted this
following a typhoon which flooded and devastated the with: needed. You though it is also your chance to share what impending death?
whole province. Finding safe housing for survivors, you can do for others. What will be your most
organizing support for the family, organizing counseling a. Acetone important role where you can demonstrate the impact a. "I'm ready to do."
debriefing sessions and securing physical care are the b. Alcohol of nursing health? b. "I have resigned myself to dying"
services you are involved with. To which type of c. Ammonia c. "What's the use"?
prevention are these activities included. d. Bleach a. Conduct health education on healthy lifestyle d: "I'm giving up"
b. Be a triage nurse
a. Tertiary prevention 47. You are a member of the infection control team, of c. Take the initial history and document findings 55. Maria, 90 years old has planned ahead for her-
b. Primary prevention the hospital. Based on a feedback during the meeting of d. Act as a coordinator death-philosophically, socially, financially and
c. Aggregate care prevention the committee there is an increased incidence of emotionally. This is recognized as:
d. Secondary prevention pseudomonas infection in the Burn Unit (3 out of 10 Situation 11 - One of the realities that we are confronted
patients had positive blood and wound culture). What with is'6w mortality. It is important for us nurses to be a. Acceptance that death is inevitable
43. During the disaster you see a victim with a green is your priority activity? aware of how we view suffering, pain, illness, and even b Avoidance of the true sedation
tag, you know that the person: our death as well as its meaning. That way we can help c. Denial with planning for continued life
a. Establish policies for surveillance and monitoring our patients cope with death and dying. d. Awareness that death will soon occur
a. has injuries that are significant and require medical b. Do data gathering about the possible sources of
care but can wait hours will threat to life or limb infection (observation, chart review, interview) 51. Irma is terminally ill she speaks to you in Situation 12 - Brain tumor, whether malignant or benign,
b. has injuries that are life threatening but survival is c. Assign point persons who can implement policies confidence. You now feel that Irma's family could be has serious management implications nurse, you should
good with minimal intervention d. Meet with the nursing group working in the burn unit helpful if they knew what Irma has told you. What be able to understand the consequences of the disease
c. indicates injuries that are extensive and chances of and discuss problem with them feel should you do first? and the treatment.
survival are unlikely even with definitive care
d. has injuries that are minor and treatment can be 48. Part of your responsibility as a member of the a. Tell the physician who in turn could tell the family 56. You are caring for Conrad who has a brain tumor
delayed from hours to days diabetes core group is to get referrals from the various b. Obtain Irma's permission to share the information and increased intracranial Pressure (ICP). Which
wards regarding diabetic patients needing diabetes with the family intervention should you include in your plan to reduce
44. The term given to a category of triage that refers to education. Prior to discharge today 4 patients are c. Tell Irma that she has to tell her family what she told ICP?
life threatening or potentially life threatening injury or referred to you. How would you start prioritizing your you
illness requiring immediate treatment: activities? d. Make an appointment to discuss the situation with a. Administer bowel! Softener
the family b. Position Conrad with his head turned toward the side
a. Immediate a. Bring your diabetes teaching kit and start your session of the tumor
b. Emergent taking into consideration their distance from your office 52. Ruby who has been told she has terminal cancer c. Provide sensory stimulation
c. Non-acute b. Contact the nurse-in-charge and find out from her the turns away aha refuses to respond to you. You can best d. Encourage coughing and deep breathing
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c. Aris, who is newly admitted and is scheduled for an c. training on disaster is not important to the response in
57. Keeping Conrad's head and neck in alignment executive check-up a. Urinary retention the event of a real disaster because each disaster is
results in: d. Claire, who has cholelithiasis and is for operation on b. Abnormal vaginal or perineal discharge unique in itself
call c. Paresthesia of the lower extremities d. do the greatest good for the greatest number of
a. increased intrathoracic pressure d. Nausea and vomiting and diarrhea casualties
b. increased venous outflow 63. Brenda, the Nursing Supervisor of the intensive care
c. decreased venous outflow unit (ICU) is not on duty when a staff nurse committed 68. Which of the following can be used on the 73. Which of the following categories of conditions
d. increased intra abdominal pressure a serious medication error. Which statement accurately irradiated skin during a course of radiation therapy? should be considered first priority in a disaster?
reflects the accountability of the nursing supervisor?
58. Which of the following activities may increase a. Adhesive tape a. Intracranial pressure and mental status
intracranial pressure (ICP)? a. Brenda should be informed when she goes back on b. Mineral oil b. Lower gastrointestinal problems
duty c. Talcum powder c. Respiratory infection
a. Raising the head of the bed b. Although Brenda is not on duty, the nursing supervisor d. Zinc oxide ointment d. Trauma
b. Manual hyperventilation on duty decides to call her if time permits
c. Use of osmotic Diuretics c. The nursing supervisor on duty will notify Brenda at 69. Earliest sign of skin reaction to radiation therapy is: 74. A guideline that is utilized in determining priorities
d. Valsava's maneuver home is to assess the status of the following, EXCEPT?
d. Brenda is not duty therefore it is not necessary to a. desquamation
59. After you assessed Conrad, you suspected increased inform her b. erythema a. perfusion
ICP! Your most appropriate respiratory goal is to: c. atrophy b. locomotion
64. Which barrier should you avoid, to manage your d. pigmentation c. respiration
a. maintain partial pressure of arterial 02 (PaO2) above time wisely? d. mentation
80 mmHg 70. What is the purpose of wearing a film badge while
b. lower arterial pH a. Practical planning caring for the patient who is radioactive? 75. The most important component of neurologic
c. prevent respiratory alkalosis b. Procrastination assessment is:
d. promote CO2 elimination c. Setting limits a. Identify the nurse who is assigned to care for such a
d. Realistic personal expectation patient a. pupil reactivity
60. Conrad underwent craniotomy. As his nurse; you b. Prevent radiation-induced sterility b. vital sign assessment
know that drainage on a craniotomy dressing must be 65. You are caring for Vincent who has just been c. Protect the nurse from radiation effects c. cranial nerve assessment
measured and marked. Which findings should you transferred to the private room. He is anxious because d. Measure the amount of exposure to radiation d. level of consciousness/responsiveness
report immediately to the surgeon? he fears he won't be monitored as closely as he was in
the Coronary Care Unit. How can you allay his fear? Situation 15 - In a disaster there must be a chain of Situation 16 - You are going to participate in a Cancer
a. Foul-smelling drainage command in place that defines the roles of each Consciousness Week. You are assigned to take charge of
b. yellowish drainage a. Move his bed to a room far from nurse's station to member of the response team. Within the health care the women to make them aware of cervical cancer. You
c. Greenish drainage reduce group there are pre-assigned roles based on education, reviewed its manifestations and management.
d. Bloody drainage b. Assign the same nurse to him when possible experience and training on disaster.
c. Allow Vincent uninterrupted period of time 76. The following are risk factors for cervical Cancer
Situation 13 -As a Nurse, you have specific d. Limit Vincent's visitors to coincide with CCU policies 71. As a nurse to which of the following groups are you EXCEPT:
responsibilities as professional. You have to demonstrate best prepared to join?
specific competencies. Situation 14 - As a nurse in the Oncology Unit, you have a. immunisuppressive therapy
to be prepared to provide efficient and effective care to a. Treatment group b. sex at an early age, multiple partners, exposure to
61. The essential components of professional nursing your patients. b. Triage group socially transmitted diseases, male partner's sexual
practice are all the following EXCEPT: c. Morgue management habits
66. Which one of the following nursing interventions d. Transport group c. viral agents like the Human Papilloma Virus
a. Culture would be most helpful in preparing the patient for d. smoking
b. Care radiation therapy? 72. There are important principles that should guide
c. Cure the triage team in disaster management that you have 77. Late signs and symptoms of cervical cancer include
d. Coordination a. Offer tranquilizers and antiemetics to know if you were to volunteer as part of the triage the following EXCEPT:
b. Instruct the patient of the possibility of radiation burn team. The following principles should be observed in
62. You are assigned to care for four (4) patients. Which c. Emphasis on the therapeutic value of the treatment disaster triage, EXCEPT: a. urinary/bowel changes
of the following patients should you give first priority? d. Map out the precise course of treatment b. pain in pelvis, leg of flank
a. any disaster plan should have resource available to c. uterine bleeding
a. Grace, who is terminally ill with breast cancer 67. What side effects are most apt to occur to patient triage at each facility and at the disaster site if possible d. lymph edema of lower extremities
b. Emy, who was previously lucid but is now unarousable during radiation therapy to the pelvis? b. make the most efficient use of available resources
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78. When a panhysterectomy is performed due to d. aspirin 93. You would like to compare the support, system of
cancer of the cervix, which of the following organs are a. Place pillows under your patient's shoulders patients with chronic illness to those with acute illness.
moved? b. Raise the knee-gatch to 30 degrees 89. Which of the following term most precisely refer to What type of research it this?
c. Keep your patient in a high-fowler's position an infection acquired in the hospital that was not
a. the uterus, cervix, and one ovary d. Support the patient's head and neck with pillows and present or incubating at the time of hospital a. Correlational
b. the uterus, cervix, and two-thirds of the vagina sandbags admission? b. Descriptive
c. the uterus, cervix, tubes and ovaries c. Experimental
d. the uterus and cervix 84. If there is an accidental injury to the parathyroid a. Secondary bloodstream infection d. Quasi-experimental
gland during a thyroidectomy which of the following b. Nosocomial infection
79. The primary modalities of treatment for Stage 1 and might Leda develops postoperative? c. Emerging infectious disease 94. You are shown a Likert Scale that will be used in
IIA cervical cancer include the following: d. Primary bloodstream infection evaluating your performance in the clinical area. Which
a. Cardiac arrest of the following questions will you not use in critiquing
a. surgery, radiation therapy and hormone therapy b. Dyspnea 90. Which of the following guidelines is not appropriate the Likert Scale?
b. surgery c. Respiratory failure to helping family members cope with sudden death?
c. radiation therapy d. Tetany a. Are the techniques to complete and score the scale
d. surgery and radiation therapy a. Obtain orders for sedation of family members provided?
85. After surgery Leda develops peripheral numbness, b. Provide details of the factors attendant to the sudden b. Are the reliability and validity information on the scale
80. A common complication of hysterectomy is: tingling and muscle twitching and spasm. What would death described?
you anticipate to administer? c. Show acceptance of the body by touching it and giving c. If the Likert Scale is to be used for a study, was the
a. thrombophlebitis of the pelvic and thigh vessels the family permission to touch development process described?
b. diarrhea due to over stimulating a. Magnesium sulfate d. Inform the family that the patient has passed on d. Is the instrument clearly described?
c. atelectasis b. Calcium gluconate
d. wound dehiscence c. Potassium iodine Situation 19 - As a nurse you are expected to participate 95. In any research study where individual persons are
d. Potassium chloride in initiating or participating in the conduct of research involves, it is important that an informed consent for
Situation 17 - The body has regulatory mechanism to studies to improve nursing practice. You have to be the Study is obtained. The following are essential
maintain the needed electrolytes. However there are Situation 18 - NURSES are involved in maintaining a safe updated on the latest trends and issues affecting information about the consent that you should disclose
conditions/surgical interventions that could compromise and health environment. This is part of quality care profession and the best practices arrived at by the to the prospective subjects EXCEPT:
life. You have to understand how management of these management. profession
conditions are done. a. Consent to incomplete disclosure
86. The first step in decontamination is: 91. You are interested to study the effects of b. Description of benefits, risks and discomforts
81. You are caring for Leda who is scheduled to undergo meditation and relaxation on the pain experienced by c. Explanation of procedure
total thyroidectomy because of a diagnosis of thyroid a. to immediately apply a chemical decontamination cancer patients. What type of variable is pain? d. Assurance of anonymity and confidentiality,
cancer. Prior to total thyroidectomy, you should foam to the area of contamination
instruct Leda to: b. a thorough soap and water was and rinse of the a. Dependant Situation 20 - Because severe burn can affect the
patient b. Correlational person's totality it is important that you apply
a. Perform range and motion exercises on the head and c. to immediately apply personal protective equipment c. Independent interventions focusing on the various dimensions of
neck d. removal of the patients clothing and jewelry and then d. Demographic man. You also have to understand the rationale of the
b. Apply gentle pressure against the incision when rinsing the patient with water treatment.
swallowing 92. You would like to compare the support system of
c. Cough and deep breath every 2 hours 87. For a patient experiencing pruritus, you recommend patients with chronic illness to those with acute illness. 96. What type of debribement involves proteolytic
d. Support head with the hands when changing position which type of bath: How will you best state your problem? enzymes?
82. As Leda's nurse, you plan to set up an emergency a. Water a. A descriptive study to compare the support system of a. Interventional
equipment at her beside following thyroidectomy. You b. colloidal (oatmeal) patients with chronic illness and those with acute illness b. Mechanical
should include: c. saline in terms of demographic data and knowledge about c. Surgical
d. sodium bicarbonate interventions d Chemical
a An airway and rebreathing tube b. The effect of the Type of Support system of patients
b. A tracheostomy set and oxygen 88. Induction of vomiting is indicated for the accidental with chronic illness and those with acute illness 97. Which topical antimicrobial is most frequently used
c. A crush cart .with bed board poisoning patient who has ingested. c. A comparative analysis of the support: system of in burn wound care?
d. Two ampules of sodium bicarbonate patients with chronic illness and those with acute illness
a. rust remover d. A study to compare the support system of patients a. Neosporin
83. Which of the following nursing interventions is b. gasoline with chronic illness and those with acute illness b. Silver nitrate
appropriate after a total thyroidectomy? c. toilet bowl cleaner c. Silver sulfadiazine
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d. Sulfamylon ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC 51. C

AND PSYCHOSOCIAL ALTERATIONS 52. A
98. Hypertrophic burns scars are caused by: 53. D
1. A 54. A
a. exaggerated contraction 2. D 55. D
b. random layering of collagen 3. D 56. A
c. wound ischemia 4. B 57. B
d. delayed epithelialization 5. D 58. B
6. A 59. D
99. The major disadvantage of whirlpool cleansing of 7. B 60. A
burn wounds is: 8. A 61. A
9. D 62. B
a. patient hypothermia 10. A 63. A
b. cross contamination of wound 11. B 64. B
c. patient discomfort 12. B 65. B
d. excessive manpower requirement 13. B 66. C
14. C 67. A
100. Oral analgecis are most frequently used to control 15. B 68. D
burn injury pain: 16. C 69. B
17. C 70. C
a. upon patient request 18. C 71. B
b. during the emergent phase 19. A 72. C
c. after hospital discharge 20. C 73. D
d. during the cute phase 21. C 74. B
22. A 75. D
23. A 76. A
24. D 77. B
25. A 78. C
26. D 79. D
27. A 80. A
28 D 81. C
29. C 82. B
30. D 83. C
31. D 84. D
32. D 85. B
33. B 86. C
34. C 87. B
35. D 88. D
36. B 89. B
37. D 90. A
38. B 91. A
39. C 92. C
40. C 93. A
41. B 94. A
42. C 95. A
43. D 96. D
44. D 97. B
45. A 98. A
46. D 99. A
47. A 100. C
48. C
49. B
50. A
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Nursing Practice Test V personalities may marry repeatedly or get into trouble
with legal authorities is: a. The patient should be put on a special diet a. Secretaries
Situation: The nurse is interviewing a handsome man. He b. The medication should be given only at night b. Elderly
is intelligent and very charming. When asked about his a. They usually just don't care c. A salt-free should be provided for the patient c. Students
family, he states he has been married four times. He says b. They are borderline mentally retarded d. The drug level should be monitored regularly d. Professionals
three of those marriages were "shotgun" weddings. He c. They are too psychotic to see what’s going on
states he never really loved any of his wives. He doesn't d. They do not learn from past mistakes 13. The nursing plan should emphasize: 19. The best intervention is:
know much about his three children. "I've lost track," he
states. 7. The nurse recognizes that these are traits of: a. Offering him finger foods a. Tell her it just takes a long time
b. Telling him he must sit down and eat b. Ask her if her husband is angry
1. If a patient is very resistant in taking responsibility of a. Bipolar disorder c. Serving food in his room and staying with him c. Refer her and her husband to sex therapy
his action and asks, "Can you just give me some b. Alcoholic personality d. Telling him to order fast food of he wants to eat d. Tell her she is suffering PTSD
medication?" the best response is: c. Antisocial personality
d. Borderline personality Situation: Anna, 25 years old was raped six months ago Situation: Obsessions are recurring thoughts that
a. "The medication has too many side effects." states, "I just can't seem to get over this. My husband become prevalent in the consciousness and may be
b. You don't want to take medication, do you?" Situation: The patient with bipolar disorder is pacing and I don't even have sex anymore. What can I do?" considered as senseless or repulsive white compulsion
c. Medication is given only as a East resort." continuously and is skipping meals. are the repetitive acts that follow obsessive thoughts.
d. "There is no medication specific for your condition." 14. Supportive therapy to the rape victim is directed at
8. Blood levels are drawn on the patient who has been overwhelming feeling that the victim experiences just 20. To understand the meaning of the cleaning rituals,
2. The patient asks the nurse, "What is this therapy for taking Lithium for about six months. The present level after the rape has occurred? the nurse must realize:
anyway. I just don't understand it." the best reply is: is 2.1 meq/L. The nurse evaluates this level as:
a. Guilt a. The patient cannot help herself
a. "It keeps you from being put on medications." a. Therapeutic b. Rage b. The patient cannot change
b. "It helps you to change others in the family." b. Below therapeutic c. Damaged c. Rituals relieve intense anxiety
c. "The purpose of therapy is to help you change." c. Potentially dangerous d. Despair d. Medications cannot help
d. "No one but professionals can really understand d. Fatally toxic
15. Anna asks, "Why do I need to have pelvic exam?" 21. Upon admission to the hospital the patient
3. For patient in group therapy, the goal is: 9. The priority in working with patient a thought The nurse explains: increases the ritual behavior at bedtime. She cannot
disorder is: sleep. The treatment plan should include:
a. Exchanging information and ideas a. "To make sure you're not pregnant."
b. Developing insight by relating to others a. Get him to understand what you're saying b. "To see if you got an infection." a. Recommending a sedative medication
c. Learning that everyone has problems b. Get him to do his ADLs c. "To make sure you were really raped." b. Modifying the routine to diminish her bedtime anxiety
d. All of the above c. Reorient him to reality d. "To gather legal evidence that is required." c. Reminding her to perform rituals early in the evening
d. Administer antipsychotic medications d. Limit the amount of time she spends washing her
4. In planning care for the patient with a personality 16. In providing support therapy, the nurse explains hands
disorder, the nurse realizes that this patient will most 10. The most recent Lithium level on bipolar patient that rape has nothing to do with sexual desires or
likely: indicates a drop non-therapeutic level. What associated heeds. The two most common elements in rape are: 22. A patient has been diagnosed with a personality
behavior does the nurse assess? disorder with .compulsive traits. Of the following
a. Not need long-term therapy a. Guilt and shame behavior's, which one would you expect the patient to
b. Not require medication a. Ataxia b. Shame and jealousy exhibit?
c. Require anti-anxiety medication b. Confusion c. Embarrassment and envy
d. Resist any change in behavior c. Hyperactivity d. Power and anger a. Inability to make decisions
d. Lethargy b. Spontaneous playfulness
5. The person with an antisocial personality is 17. The rape victim will not talk, is withdrawn and c. Inability to alter plans
participating in therapy while a patient at a psychiatric 11. Adequate fluid intake for a patient on Lithium is: depressed. The defensive mechanism being used is: d. Insistence that things be done his way
hospital. The nurse’s expectations are that he will:
a. 1,000 ml per day a. Rationalization 23. The patient will not be able to stop her compulsive
a. Make a complete recovery b. 1,500 ml per day b. Denial washing routines until she:
b. Make significant changes c. 2,000 ml per day c. Repression
c. Begin the slow process of change d. 3,600 ml per day d. Regression a. Acquires more superego
d. Make few changes, if any b. Recognizes the behavior is unrealistic
12. The physician orders Lithium carbonate for the 18. The composite picture of rape victim reveals that c. No longer needs them to manage her feelings of
6. One of the reasons that persons with antisocial bipolar patient. The nurse is aware that: most victimized women are: anxiety
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d. Regains contact with reality problem in this country. 34. The patient has a blood pressure of 180/100, heart
rate of 120, associated with extreme restlessness. He is a. Rationalization
24. A 48-year-old female patient is brought to the 29. The nurse is monitoring a drug abuser who states very suspicious of the hospital environment and actions b. Projection
hospital by her husband because her behavior is he was given cocaine and heroine that war cut with of healthcare workers. The nurse should confront this c. Compensation
blocking her ability to meet her family's needs. She has cornstarch or some other kind of powder. He states, "It patient on abuse of; d. Substitution
uncontrollable and constant desire to scrub her hands, was really bad stuff." Which complication is most
the walls, floors and sofa. She keeps repeating," threatening to this patient? a. Marijuana 40. An unattractive girl becomes a very good student.
Everything is dirty." This is an example of: b. Cocaine This is an example of:
a. Endocarditis c. Barbiturates
a. Compulsion b. Gangrene d. Tranquilizers a. displacement
b. Obsession c. Pulmonary abscess b. Regression
c. Delusion d. Pulmonary embolism 35. The nursing interventions most effective in working c. Compensation
d. Hallucination with substance dependent patients are: d. Projection
30. The chronic drug abuser is suffering lymphedema in
25. The female patient is preoccupied with rules and all extremities, but particularly in the arm where the a. Firm and directive 41. A patient has been sharing a painful experience of
regulations. She becomes upset if others do not follow drug was obviously injected. There is severe b. Instillation of values sexual abuse during his childhood. Suddenly he stops
her lead and adhere to the rules exactly. This is a obstruction of veins and lymphatics. The nurse suspects c. Helpful and advisory and says, “l can't remember any more." The nurse
characteristic of which of the following personality? the patient used: d Subjective and non-judgmental assesses his behavior as:
a. Compulsive a. A dull, contaminated needle 36. An adolescent patient has bloodshot eyes, a a. Stubbornness
b. Borderline b. A needle contaminated with AIDS voracious appetite (especially for junk foods), and a dry b. Forgetfulness
c. Antisocial c. Contaminated drugs mouth. Which drug of abuse would the nurse most c. Blocking
d. Schizoid d. Cocaine mixed with uncut heroin likely suspect? d. Transference
26. In planning care focused on decreasing the patient's 31. The nurse is assessing a heroin user who injected a. Marijuana 42. The patient has a phobia about walking down in
anxiety, what plan should the nurse have in regards to the drug into an artery instead of a vein. Which b. Amphetamines dark halls. The nurse recognizes that the coping
the rituals? complication is the nurse most likely to expect? c. Barbiturates mechanism usually associated with phobia is:
d. Anxiolytics
a. Encourage the routines a. Infection a. Compensation
b. Ignore rituals b. Cardiac dysrhythmias Situation: Defense mechanisms are unconscious b. Denial
c. Work with her to develop limits of behavior c. Gangrene intrapsychic process implemented to cope with anxiety. c. Conversion
d. Restrain her from the rituals d. Thrombophlebitis The use of some of these mechanisms is healthy, while d. Displacement
she use of others is unhealthy.
27. After the patient entered the hospital she began to 32. The nurse is assessing a 16-year-old patient for drug 43. The patient is denying that he is an alcoholic He
increase her ritualistic hand washing at bedtime and abuse. The patient is incoherent. Because she notes 37. A patient cries and curls in a fetal position refusing states that his wife is an alcoholic. The defense
could; not sleep. The nurse plans care around the fact irritation of eyes, nose and mouth, she suspects to move or talk. This is an example of: mechanism he is utilizing is: v
that this patient needs: inhalants. Which sign is most indicative of inhalant
abuse? a. Regression a. Sublimation
a. A substitute activity to relieve anxiety b. Suppression b. Projection
b. Medication for sleeping a. Vomiting c. Conversion c. Suppression
c. Anti-anxiety medication such as Xanax b. Bad breath d. Sublimation d. Displacement
d. More scheduled activities during the day c. Bad trip
d. Sudden fear 38. A person who expands sexual energy in a Situation: Ms. Dwane, 17 years old, is admitted with
28. The patient states, "I know all this scrubbing is silly nonsexual, socially accepted way is using the coping anorexia nervosa. You have been assigned to sit with her
but I can’t help it:'', this statement indicates that the 33. An impaired nurse has been admitted for treatment mechanism of. while she eats her dinner. Ms. Dwane says "My primary
patient does not recognize: of Demerol addiction. She asks, "When will the nurse trusts me. I don't see why you don't."
withdrawal begin?" the best response is: a. Projection
a. What she is doing b. Conversion 44. Which observation of the client with anorexia
b. Why she is cleaning a. "It varies, with each individual." c. Sublimation nervosa indicates the client is improving?
c. Her level of anxiety b. "There is no way to tell." d. Compensation
d. Need for medication c. "Withdrawal begins soon after the last dose." a. The client eats meats in the dining room
d. "It depends upon how well the Demerol works." 39. "The reason I did not do well on the exam is that I b. The client gains one pound per week
Situation: Substance, abuse is a common, growing health was tired." This is an example of: c. The client attends group therapy sessions
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d. The client has a more realistic self-concept negativistic behavior. Her family states that Raul is in
Situation: The nurse suspects a client is denying his a. Get rid of the major stressor good health. Raul asks you, "Where am I?"
45. The nurse is caring for a client with anorexia feelings of anxiety b. Change lifestyle completely
nervosa who is to be placed on behavioral c. Modify responses to stress 60. Another patient, Mr. Pat, has been brought to the
modification. Which is appropriate to include in (he 50. The nurse is monitoring a patient who is d. Learn new ways of thinking psychiatric unit and is pacing up and down the hall. The
nursing care plan? experiencing increasing anxiety related to recent nurse is to admit him to the hospital. To establish a
accident. She notes an increase in vital signs from 56. Another client walks in to the mental health nurse-client relationship, which approach should the
a. Remind the client frequently to eat all the food served 130/70 to 160/30, pulse rate of 120, respiration 36. He outpatient center and States, "I've had it. I can't go on nurse try first?
on the tray is having difficulty communicating. His level of anxiety any longer. You've got to help me. "The nurse asks the
b. Increased phone calls allowed for client by one per day is: client to be seated in a private interview room. Which a. Assign someone to watch Mr. Pat until he is calm
for each pound gained action should the nurse take next? b. Ask Mr. Pat to sit down and orient him to the nurse's
c. Include the family of the client in therapy sessions two a. Mild name and the need for information
times per week b. Moderate a. Reassure the client that someone will help him soon c. Check Mr. Pat's vital signs, ask him about allergies, and
d. Weigh the client each day at 6:00 am in hospital gown c. Severe b. Assess the client's insurance coverage call the physician for sedation
and slippers after she voids d. Panic c. Find out more about what is happening to the client d. Explain the importance of accurate assessment data
d. Call the client's family to come and provide support to Mr. Pat .
46. A nursing intervention based on the behavior 51. The patient who suffers panic attacks is prescribed
modification model of treatment for anorexia nervosa a medication for short-term therapy. The nurse 57. Mr. Juan is admitted for panic attack. He frequently 61. If Raul will say "I'm so afraid! Where I am? Where is
would be: prepares to administer. experiences shortness of breath, palpitations, nausea, my family'?" How should the nurse respond?
diaphoresis, and terror. What should the nurse include
a. Role playing the client's interaction with her parents a. Elavil in the care plan for Mr. Juan? When he is shaving a a. "You are in the hospital and you're safe here. Your
b. Encouraging the client to vent her feelings through b. Librium panic attack? family will return at 10 o'clock, which is one hour from
exercise c. Xanax now"
c. Providing a high-calorie, high protein diet with d. Mellaril a. Calm reassurance, deep breathing and medications as b. "You know were you are. You were admitted here 2
between meals snacks ordered weeks ago. Don’t worry your family will be back soon."
d. Restricting the client's privileges until she gains three 52. In attempting to control a patient who is suffering b. Teach Mr. Juan problem solving in relation to his c. "I just told you that you're in the hospital and your
pounds panic attack, the nursing priority is: anxiety family will be here soon."
c. Explain the physiologic responses of anxiety d. "The name of the hospital is on the sigh over the door.
47. While admitting Ms. Dwane, the nurse discovers a a. Provide safely d. Explore alternate methods for dealing with the cause Let's go read it again."
bottle of pills that Ms. Dwane calls antacids. She takes b. Hold the patient of his anxiety
them because her stomach hurts. The nurse's best c. Describe crisis in detail 62. Raul has had difficulty sleeping since admission.
initial response is: d. Demonstrate ADLs frequently 58. Ms. Wendy is pacing about the unit and wringing Which of the following would be the best intervention?
his hands. She is breathing rapidly and complains of
a. Tell me more about your stomach pain 53. Which assessment would the nurse most likely find palpitations and nausea, and she has difficulty focusing a. Provide him with glass of warm milk
b. These do not look like antacids. I need to get an order in a person who is suffering increased anxiety? on what the nurse is saying. She says she is having a b. Ask the physician for a mild sedative
for you to have them heart attack but refuses to rest. The nurse would c. Do not allow Raul to take naps during the day
c. Tell me more about you drug use a. Increasing BP, increasing heart rate and respirations interpret her level of anxiety as: d. Ask him family what they prefer
d. Some girls take pills to help them lose weight b. Decreasing BP, heart rate and respirations
c. Increased BP and decreased respirations a. Mild 63. Which activity would you engage in Raul at the
48. The primary objective in the treatment of the d. Increased respirations and decreased heart rate b. Moderate nursing home?
hospitalized anorexic client is to: c. Severe
54. A patient who suffers an acute anxiety disorder d. Panic a. Reminiscence groups
a. Decrease the client's anxiety approaches the nurse and while clutching at his shirt b. Sing-along
b. Increase the insight into the disorder states "I think I'm having a heart attack." The priority 59. When assessing this client, the nurse must be d. Discussion groups
c. Help the mother to gain control nursing action is: particularly alert to: c. Exercise class
d. Get the client to ea and gain weight
a. Reassure him he is OK a. Restlessness 64. Which of the following would be an appropriate
49. Your best response for Ms. Dwane is: b. Take vital signs stat b. Tapping of the feet strategy in reorienting a confused client to where her
c. Administer Valium IM c. Wringing of the hands room is?
a. I do trust you, but I was assigned to be with you d. Administer Xanax PO d. His or her own anxiety level
b. It sounds as if you are manipulating me a. Place pictures of her family on the bedside stand
c. Ok, when I return, you should have eaten everything 55. In teaching stress management, the goal of therapy Situation: Raul aged 70 was recently admitted to a b. Put her name in large letters on her forehead
d. Who is your primary nurse? is to: nursing home because of confusion, disorientation, and c. Remind the client where her room is
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d. Let the other residents know where the client’s room d. "What caused you to think you were God?" 75. Which of the following is an example of a negative c. Affect more women than men
is symptom of schizophrenia? d. May be related to certain medical conditionsa
70. The nurse is caring for a client who is experiencing
65. The best response for the nurse to make is: auditory hallucination. What would be most crucial for a. Delusions 80. A patient with schizophrenia (catatonic type) is
the nurse to assess? b. Disorganized speech mute and can't perform activities of daily living. The
a. Don't worry, Raul. You're safe here c. Flat affect patient stares out the window for hours. What is your
b. Where do you think you are? a. Possible hearing impairment d. Catatonic behavior first priority in this situation?
c. What did your family tell you? b. Family history of psychosis
d. You're at the community nursing home c. Content of the hallucination 76. The patient tells you that a "voice" keeps laughing a. Assist the patient with feeding
d. Otitis media at him and tells him he must crawl on his hands and b. Assist the patient with showering and tasks for
Situation: The police bring a patient to the emergency knees like a dog. Which of the following would be the hygiene
department. He has been locked in his apartment for the 71. A patient with schizophrenia reports that the most appropriate response? c. Reassure the patient about safely, and try to orient
past 3 days, making frequent calls to the police and newscaster on the radio has a divine message him to his surroundings
emergency services and stating that people are trying to especially for her. You would interpret this as a. "They are imaginary voices and we're here to make d. Encourage, socialization with peers, and provide a
kill him. indicating. them go, away." stimulating environment
b. "If it makes you feel better, do what the voices tell
66. A client on an inpatient psychiatric unit refuses to a. Loose of associations you." 81. Which of the following would you suspect in a
eat and states that the staff is poisoning her food. b. Delusion of reference c. "The voices can't hurt you here in the hospital" patient receiving Chlorpromazine (Thorazine) who
Which action should the nurse include in the client's c. Paranoid speech d. "Even though I don't hear the voices, I understand that complains of a sore throat and has a fever?
care plan? d. Flight of ideas you do."
a. An allergic reaction
a. Explain to the client that the staff can be trusted 72. What type of delusions is the patient experiencing? 77. A 23-year-old patient is receiving antipsychotic b. Jaundice
b. Show the client that others eat the food without harm medication to treat his schizophrenia. He's c. Dyskinesia
c. Offer the client factory-sealed foods and beverages a. Persecutory experiencing some motor abnormalities called d. Agranulocytosis
d. Institute behavioral modification with privileges b. Grandiose extrapyramidal effects. Which of the following
dependent on intake c. Jealous extrapyramidal effects occurs most frequently in 82. While providing information for the family of a
d. Somatic younger make patients? patient with schizophrenia, you should be sure to
67. The client tells the nurse that he can't eat because inform them about which of the following
his food has been poisoned. This statement is an Situation: Helen, with a diagnosis of disorganized a. Akathisia characteristics of the disorder?
indication of which of the following? schizophrenia is creating a disturbance in the day room. b. Akinesia
She is yelling and pointing at another patient, accusing c. Dystonia a. Relapse can be prevented if the patient takes
a. Paranoia him to stealing her purse. Several patients are in the day d. Pseudoparkinsonism medication
b. Delusion of persecution room when this incident starts. b. Support is available to help family members meet their
c. Hallucination 78. Which of the following should you do next? own needs
d. Illusion 73. The nurse is preparing to care for a client diagnosed c. Improvement should occur if the patient's
with catatonic schizophrenia. In anticipation of this a. Firmly redirect the patient to her room to discuss the environment is carefully maintained
68. The client on antipsychotic drugs begins to exhibit client's arrival, what should the nurse do? incident d. Stressful situations in the family in the family can
signs and symptoms of which disorder? b. Call the assistance and place the patient in locked precipitate a relapse in the patient
a. Notify security seclusion
a. Akinesia b. Prepare a magnesium sulfate drip c. Help the patient look for her purse 83. While caring for John, the nurse knows that John
b. Pseudoparkinsonism c. Place a specialty mattress overlay on the bed d. Don't intervene - the patients need a little bit of room may have trouble with:
c. Tardive dyskinesia d. Communicable the client's nothing-by-mouth status to in which to work out differences
d. Oculogyric crisis the dietary department a. Staff who are cheerful
Situation: John is admitted with a diagnosis of paranoid b. Simple direct sentences
69. During a patient history, a patient state that she 74. The nurse is caring for a client whom she suspects is schizophrenia. c. Multiple commands
used to believe she was God. But she knows this isn't paranoid. How would the nurse confirm this d. Violent behaviors
true. Which of the following would be your best assessment? 79. You're reaching a community group about
response?" schizophrenia disorders. You explain the different types 84 Which nursing diagnosis is most likely to be
a. indirect questioning of schizophrenia and delusional disorders. You also associated with a person who has a medical diagnosis
a. "Does it bother you that you used to believe that b. Direct questioning explain that, unlike schizophrenia, delusional disorders: of schizophrenia, paranoid type?
about yourself?" c. Les-ad-in-sentences
b. "Your thoughts are now more appropriate" d. Open-ended sentences a. Tend to begin in early childhood a. Fear of being along
c. "Many people have these delusions." b. Affect more men than women b. Perceptual disturbance related to delusion of
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persecution hospital stimulated her anger by using a condescending tone of

c. Social isolation related to impaired ability to trust b. Provide nutritious food and a quite place to rest 95. When preparing to conduct group therapy, the voice. Which of the following responses by the nurse
d. Impaired social skills related to inadequate developed c. Protect the client and others from harm nurse keeps in mind that the optimal number of clients would be the most therapeutic?
superego d. Create a structured environment in a group would be:
a. "I feel angry when I hear that tone of voice"
85. Which of the following behaviors can the nurse Situation: Wendell, 24 year-old student with a primary a. 6 to 8 b. "You make me so angry when you talked to me that
anticipate with this client? sleep disorder, is unable to initiate maintenance of b. 10 to 12 way."
sleep. Primary sleep disorders may be categorized as c. 3 to 5 c. "Are you trying to make me angry?"
a. Negative cognitive distortions dyssomnias or parasomnias. d. Unlimited d. "Why do you use that condescending tone of voice
b. Impaired psychomotor development with me?"
c. Delusions of grandeur and hyperactivity 91. The nurse is caring for a client who complains; of 96. What occurs during the working phase of the-nurse-
d. Alteration of appetite and sleep pattern fat?gue, inability to concentrate, and palpitations. The client relationship? 100. A 35 year-old client tells the nurse that he never
client stales that she has been experiencing these disagrees with anyone and that he has loved everyone
Situation: A client is admitted to the hospital. During the symptoms for the past 6 months. Which factor in the a. The nurse assesses the client's needs and develops a he's ever known. What would be the nurse's best
assessment the nurse notes that the client has not slept client’s history has most likely contributed to.these plan of care response to this client?
for a week. The client is talking rapidly, and throwing his symptoms? b. The nurse and client together evaluate and modify the
arms around randomly. goals of the relationship a. "How do you manage to do that?"
a. History of recent fever c. The nurse and client discuss their feelings about b. "That's hard to believe. Most people couldn't to that."
86. When writing an assessment of a client with mood b. Shift work terminating the relationship c. "What do you do with your feelings of dissatisfaction
disorder, the nurse should specify: c. Hyperthyroidism d. The nurse and client explore each other's expectations or anger?"
d. Fear of-the relationship d. "How did you come to adopt such a way of life?"
a. How flat the client's affect
b. How suicidal the client is 92. If Wendell complains of experiencing an 97. A 42 year-old homemaker arrives at the emergency
c. How grandiose the client is overwhelming urge to sleep and states that he's been department with uncomfortable crying and anxiety.
d. How the client is behaving falling asleep while studying and reports that these Her husband of 17 years has recently asked her for a
episodes occur about 5 times daily Wendell is most divorce. The patient is sitting in a chair, rocking back
87. It is an apprehensive anticipation of an unknown likely experiencing which sleep disorder? and forth. Which is the best response for the nurse to
danger: make?
a. Breathing-related sleep disorder
a. Fear b. Narcolepsy a. "You must stop crying so that we can discuss your
b. Anxiety c. Primary hypersomnia feelings about the divorce."
c. Antisocial d. Circadian rhythm disorder b. "Once you find a job, you will feel much better and
d. Schizoid more secure."
93. The nurse is preparing a teaching plan for a client c. "I can see how upset you are. Let's sit in the office so
88. It is an, emotional response to a consciously diagnosed with primary insomnia. Which of the that we can talk about how you're feeling."
recognized threat. following teaching topics should be included in the d. "Once you have a lawyer looking out for your
plan? interests, you will feel better."
a. Fear
b. Anxiety a. Eating unlimited spicy foods, and limiting caffeine and 98. A client on the unit tells the nurse that his wife's
c. Antisocial alcohol nagging really gets on his nerves. He asks the nurse if
d. Schizoid b. Exercising 1 hour before bedtime to promote sleep she will talk with his wife about nagging during their
c. Importance of steeping whenever the client tires family session tomorrow afternoon. Which of the
89. All but one is an example of situational crisis: d. Drinking warm milk before bed to induce sleep following would be most therapeutic response to
client?
a. Menstruation 94. Examples of dyssomnia includes:
b. Role changes a. "Tell me more specifically about her complaints"
c. Rape a. Insomnia, hypersomnia, narcolepsy b. "Can you think why she might nag you so much?"
d. Divorce b. Sleepwalking, nightmare c. "I'll help you think about how to bring this up yourself
c. Snoring while sleeping tomorrow."
90. What would be the highest priority in formulating a d. Non-rapid eye movement d. "Why do you want me to initiate this discussion in
nursing care plan for this client? tomorrow's session rather than you?"
Situation: The following questions refer to therapeutic
a. Isolate the client until he or she adjusts to 'the communication. 99. The nurse is working with a client who has just
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Nursing Practice Test V personalities may marry repeatedly or get into trouble
with legal authorities is: a. The patient should be put on a special diet a. Secretaries
Situation: The nurse is interviewing a handsome man. He b. The medication should be given only at night b. Elderly
is intelligent and very charming. When asked about his a. They usually just don't care c. A salt-free should be provided for the patient c. Students
family, he states he has been married four times. He says b. They are borderline mentally retarded d. The drug level should be monitored regularly d. Professionals
three of those marriages were "shotgun" weddings. He c. They are too psychotic to see what’s going on
states he never really loved any of his wives. He doesn't d. They do not learn from past mistakes 13. The nursing plan should emphasize: 19. The best intervention is:
know much about his three children. "I've lost track," he
states. 7. The nurse recognizes that these are traits of: a. Offering him finger foods a. Tell her it just takes a long time
b. Telling him he must sit down and eat b. Ask her if her husband is angry
1. If a patient is very resistant in taking responsibility of a. Bipolar disorder c. Serving food in his room and staying with him c. Refer her and her husband to sex therapy
his action and asks, "Can you just give me some b. Alcoholic personality d. Telling him to order fast food of he wants to eat d. Tell her she is suffering PTSD
medication?" the best response is: c. Antisocial personality
d. Borderline personality Situation: Anna, 25 years old was raped six months ago Situation: Obsessions are recurring thoughts that
a. "The medication has too many side effects." states, "I just can't seem to get over this. My husband become prevalent in the consciousness and may be
b. You don't want to take medication, do you?" Situation: The patient with bipolar disorder is pacing and I don't even have sex anymore. What can I do?" considered as senseless or repulsive white compulsion
c. Medication is given only as a East resort." continuously and is skipping meals. are the repetitive acts that follow obsessive thoughts.
d. "There is no medication specific for your condition." 14. Supportive therapy to the rape victim is directed at
8. Blood levels are drawn on the patient who has been overwhelming feeling that the victim experiences just 20. To understand the meaning of the cleaning rituals,
2. The patient asks the nurse, "What is this therapy for taking Lithium for about six months. The present level after the rape has occurred? the nurse must realize:
anyway. I just don't understand it." the best reply is: is 2.1 meq/L. The nurse evaluates this level as:
a. Guilt a. The patient cannot help herself
a. "It keeps you from being put on medications." a. Therapeutic b. Rage b. The patient cannot change
b. "It helps you to change others in the family." b. Below therapeutic c. Damaged c. Rituals relieve intense anxiety
c. "The purpose of therapy is to help you change." c. Potentially dangerous d. Despair d. Medications cannot help
d. "No one but professionals can really understand d. Fatally toxic
15. Anna asks, "Why do I need to have pelvic exam?" 21. Upon admission to the hospital the patient
3. For patient in group therapy, the goal is: 9. The priority in working with patient a thought The nurse explains: increases the ritual behavior at bedtime. She cannot
disorder is: sleep. The treatment plan should include:
a. Exchanging information and ideas a. "To make sure you're not pregnant."
b. Developing insight by relating to others a. Get him to understand what you're saying b. "To see if you got an infection." a. Recommending a sedative medication
c. Learning that everyone has problems b. Get him to do his ADLs c. "To make sure you were really raped." b. Modifying the routine to diminish her bedtime anxiety
d. All of the above c. Reorient him to reality d. "To gather legal evidence that is required." c. Reminding her to perform rituals early in the evening
d. Administer antipsychotic medications d. Limit the amount of time she spends washing her
4. In planning care for the patient with a personality 16. In providing support therapy, the nurse explains hands
disorder, the nurse realizes that this patient will most 10. The most recent Lithium level on bipolar patient that rape has nothing to do with sexual desires or
likely: indicates a drop non-therapeutic level. What associated heeds. The two most common elements in rape are: 22. A patient has been diagnosed with a personality
behavior does the nurse assess? disorder with .compulsive traits. Of the following
a. Not need long-term therapy a. Guilt and shame behavior's, which one would you expect the patient to
b. Not require medication a. Ataxia b. Shame and jealousy exhibit?
c. Require anti-anxiety medication b. Confusion c. Embarrassment and envy
d. Resist any change in behavior c. Hyperactivity d. Power and anger a. Inability to make decisions
d. Lethargy b. Spontaneous playfulness
5. The person with an antisocial personality is 17. The rape victim will not talk, is withdrawn and c. Inability to alter plans
participating in therapy while a patient at a psychiatric 11. Adequate fluid intake for a patient on Lithium is: depressed. The defensive mechanism being used is: d. Insistence that things be done his way
hospital. The nurse’s expectations are that he will:
a. 1,000 ml per day a. Rationalization 23. The patient will not be able to stop her compulsive
a. Make a complete recovery b. 1,500 ml per day b. Denial washing routines until she:
b. Make significant changes c. 2,000 ml per day c. Repression
c. Begin the slow process of change d. 3,600 ml per day d. Regression a. Acquires more superego
d. Make few changes, if any b. Recognizes the behavior is unrealistic
12. The physician orders Lithium carbonate for the 18. The composite picture of rape victim reveals that c. No longer needs them to manage her feelings of
6. One of the reasons that persons with antisocial bipolar patient. The nurse is aware that: most victimized women are: anxiety
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d. Regains contact with reality problem in this country. 34. The patient has a blood pressure of 180/100, heart
rate of 120, associated with extreme restlessness. He is a. Rationalization
24. A 48-year-old female patient is brought to the 29. The nurse is monitoring a drug abuser who states very suspicious of the hospital environment and actions b. Projection
hospital by her husband because her behavior is he was given cocaine and heroine that war cut with of healthcare workers. The nurse should confront this c. Compensation
blocking her ability to meet her family's needs. She has cornstarch or some other kind of powder. He states, "It patient on abuse of; d. Substitution
uncontrollable and constant desire to scrub her hands, was really bad stuff." Which complication is most
the walls, floors and sofa. She keeps repeating," threatening to this patient? a. Marijuana 40. An unattractive girl becomes a very good student.
Everything is dirty." This is an example of: b. Cocaine This is an example of:
a. Endocarditis c. Barbiturates
a. Compulsion b. Gangrene d. Tranquilizers a. displacement
b. Obsession c. Pulmonary abscess b. Regression
c. Delusion d. Pulmonary embolism 35. The nursing interventions most effective in working c. Compensation
d. Hallucination with substance dependent patients are: d. Projection
30. The chronic drug abuser is suffering lymphedema in
25. The female patient is preoccupied with rules and all extremities, but particularly in the arm where the a. Firm and directive 41. A patient has been sharing a painful experience of
regulations. She becomes upset if others do not follow drug was obviously injected. There is severe b. Instillation of values sexual abuse during his childhood. Suddenly he stops
her lead and adhere to the rules exactly. This is a obstruction of veins and lymphatics. The nurse suspects c. Helpful and advisory and says, “l can't remember any more." The nurse
characteristic of which of the following personality? the patient used: d Subjective and non-judgmental assesses his behavior as:
a. Compulsive a. A dull, contaminated needle 36. An adolescent patient has bloodshot eyes, a a. Stubbornness
b. Borderline b. A needle contaminated with AIDS voracious appetite (especially for junk foods), and a dry b. Forgetfulness
c. Antisocial c. Contaminated drugs mouth. Which drug of abuse would the nurse most c. Blocking
d. Schizoid d. Cocaine mixed with uncut heroin likely suspect? d. Transference
26. In planning care focused on decreasing the patient's 31. The nurse is assessing a heroin user who injected a. Marijuana 42. The patient has a phobia about walking down in
anxiety, what plan should the nurse have in regards to the drug into an artery instead of a vein. Which b. Amphetamines dark halls. The nurse recognizes that the coping
the rituals? complication is the nurse most likely to expect? c. Barbiturates mechanism usually associated with phobia is:
d. Anxiolytics
a. Encourage the routines a. Infection a. Compensation
b. Ignore rituals b. Cardiac dysrhythmias Situation: Defense mechanisms are unconscious b. Denial
c. Work with her to develop limits of behavior c. Gangrene intrapsychic process implemented to cope with anxiety. c. Conversion
d. Restrain her from the rituals d. Thrombophlebitis The use of some of these mechanisms is healthy, while d. Displacement
she use of others is unhealthy.
27. After the patient entered the hospital she began to 32. The nurse is assessing a 16-year-old patient for drug 43. The patient is denying that he is an alcoholic He
increase her ritualistic hand washing at bedtime and abuse. The patient is incoherent. Because she notes 37. A patient cries and curls in a fetal position refusing states that his wife is an alcoholic. The defense
could; not sleep. The nurse plans care around the fact irritation of eyes, nose and mouth, she suspects to move or talk. This is an example of: mechanism he is utilizing is: v
that this patient needs: inhalants. Which sign is most indicative of inhalant
abuse? a. Regression a. Sublimation
a. A substitute activity to relieve anxiety b. Suppression b. Projection
b. Medication for sleeping a. Vomiting c. Conversion c. Suppression
c. Anti-anxiety medication such as Xanax b. Bad breath d. Sublimation d. Displacement
d. More scheduled activities during the day c. Bad trip
d. Sudden fear 38. A person who expands sexual energy in a Situation: Ms. Dwane, 17 years old, is admitted with
28. The patient states, "I know all this scrubbing is silly nonsexual, socially accepted way is using the coping anorexia nervosa. You have been assigned to sit with her
but I can’t help it:'', this statement indicates that the 33. An impaired nurse has been admitted for treatment mechanism of. while she eats her dinner. Ms. Dwane says "My primary
patient does not recognize: of Demerol addiction. She asks, "When will the nurse trusts me. I don't see why you don't."
withdrawal begin?" the best response is: a. Projection
a. What she is doing b. Conversion 44. Which observation of the client with anorexia
b. Why she is cleaning a. "It varies, with each individual." c. Sublimation nervosa indicates the client is improving?
c. Her level of anxiety b. "There is no way to tell." d. Compensation
d. Need for medication c. "Withdrawal begins soon after the last dose." a. The client eats meats in the dining room
d. "It depends upon how well the Demerol works." 39. "The reason I did not do well on the exam is that I b. The client gains one pound per week
Situation: Substance, abuse is a common, growing health was tired." This is an example of: c. The client attends group therapy sessions
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d. The client has a more realistic self-concept negativistic behavior. Her family states that Raul is in
Situation: The nurse suspects a client is denying his a. Get rid of the major stressor good health. Raul asks you, "Where am I?"
45. The nurse is caring for a client with anorexia feelings of anxiety b. Change lifestyle completely
nervosa who is to be placed on behavioral c. Modify responses to stress 60. Another patient, Mr. Pat, has been brought to the
modification. Which is appropriate to include in (he 50. The nurse is monitoring a patient who is d. Learn new ways of thinking psychiatric unit and is pacing up and down the hall. The
nursing care plan? experiencing increasing anxiety related to recent nurse is to admit him to the hospital. To establish a
accident. She notes an increase in vital signs from 56. Another client walks in to the mental health nurse-client relationship, which approach should the
a. Remind the client frequently to eat all the food served 130/70 to 160/30, pulse rate of 120, respiration 36. He outpatient center and States, "I've had it. I can't go on nurse try first?
on the tray is having difficulty communicating. His level of anxiety any longer. You've got to help me. "The nurse asks the
b. Increased phone calls allowed for client by one per day is: client to be seated in a private interview room. Which a. Assign someone to watch Mr. Pat until he is calm
for each pound gained action should the nurse take next? b. Ask Mr. Pat to sit down and orient him to the nurse's
c. Include the family of the client in therapy sessions two a. Mild name and the need for information
times per week b. Moderate a. Reassure the client that someone will help him soon c. Check Mr. Pat's vital signs, ask him about allergies, and
d. Weigh the client each day at 6:00 am in hospital gown c. Severe b. Assess the client's insurance coverage call the physician for sedation
and slippers after she voids d. Panic c. Find out more about what is happening to the client d. Explain the importance of accurate assessment data
d. Call the client's family to come and provide support to Mr. Pat .
46. A nursing intervention based on the behavior 51. The patient who suffers panic attacks is prescribed
modification model of treatment for anorexia nervosa a medication for short-term therapy. The nurse 57. Mr. Juan is admitted for panic attack. He frequently 61. If Raul will say "I'm so afraid! Where I am? Where is
would be: prepares to administer. experiences shortness of breath, palpitations, nausea, my family'?" How should the nurse respond?
diaphoresis, and terror. What should the nurse include
a. Role playing the client's interaction with her parents a. Elavil in the care plan for Mr. Juan? When he is shaving a a. "You are in the hospital and you're safe here. Your
b. Encouraging the client to vent her feelings through b. Librium panic attack? family will return at 10 o'clock, which is one hour from
exercise c. Xanax now"
c. Providing a high-calorie, high protein diet with d. Mellaril a. Calm reassurance, deep breathing and medications as b. "You know were you are. You were admitted here 2
between meals snacks ordered weeks ago. Don’t worry your family will be back soon."
d. Restricting the client's privileges until she gains three 52. In attempting to control a patient who is suffering b. Teach Mr. Juan problem solving in relation to his c. "I just told you that you're in the hospital and your
pounds panic attack, the nursing priority is: anxiety family will be here soon."
c. Explain the physiologic responses of anxiety d. "The name of the hospital is on the sigh over the door.
47. While admitting Ms. Dwane, the nurse discovers a a. Provide safely d. Explore alternate methods for dealing with the cause Let's go read it again."
bottle of pills that Ms. Dwane calls antacids. She takes b. Hold the patient of his anxiety
them because her stomach hurts. The nurse's best c. Describe crisis in detail 62. Raul has had difficulty sleeping since admission.
initial response is: d. Demonstrate ADLs frequently 58. Ms. Wendy is pacing about the unit and wringing Which of the following would be the best intervention?
his hands. She is breathing rapidly and complains of
a. Tell me more about your stomach pain 53. Which assessment would the nurse most likely find palpitations and nausea, and she has difficulty focusing a. Provide him with glass of warm milk
b. These do not look like antacids. I need to get an order in a person who is suffering increased anxiety? on what the nurse is saying. She says she is having a b. Ask the physician for a mild sedative
for you to have them heart attack but refuses to rest. The nurse would c. Do not allow Raul to take naps during the day
c. Tell me more about you drug use a. Increasing BP, increasing heart rate and respirations interpret her level of anxiety as: d. Ask him family what they prefer
d. Some girls take pills to help them lose weight b. Decreasing BP, heart rate and respirations
c. Increased BP and decreased respirations a. Mild 63. Which activity would you engage in Raul at the
48. The primary objective in the treatment of the d. Increased respirations and decreased heart rate b. Moderate nursing home?
hospitalized anorexic client is to: c. Severe
54. A patient who suffers an acute anxiety disorder d. Panic a. Reminiscence groups
a. Decrease the client's anxiety approaches the nurse and while clutching at his shirt b. Sing-along
b. Increase the insight into the disorder states "I think I'm having a heart attack." The priority 59. When assessing this client, the nurse must be d. Discussion groups
c. Help the mother to gain control nursing action is: particularly alert to: c. Exercise class
d. Get the client to ea and gain weight
a. Reassure him he is OK a. Restlessness 64. Which of the following would be an appropriate
49. Your best response for Ms. Dwane is: b. Take vital signs stat b. Tapping of the feet strategy in reorienting a confused client to where her
c. Administer Valium IM c. Wringing of the hands room is?
a. I do trust you, but I was assigned to be with you d. Administer Xanax PO d. His or her own anxiety level
b. It sounds as if you are manipulating me a. Place pictures of her family on the bedside stand
c. Ok, when I return, you should have eaten everything 55. In teaching stress management, the goal of therapy Situation: Raul aged 70 was recently admitted to a b. Put her name in large letters on her forehead
d. Who is your primary nurse? is to: nursing home because of confusion, disorientation, and c. Remind the client where her room is
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d. Let the other residents know where the client’s room d. "What caused you to think you were God?" 75. Which of the following is an example of a negative c. Affect more women than men
is symptom of schizophrenia? d. May be related to certain medical conditionsa
70. The nurse is caring for a client who is experiencing
65. The best response for the nurse to make is: auditory hallucination. What would be most crucial for a. Delusions 80. A patient with schizophrenia (catatonic type) is
the nurse to assess? b. Disorganized speech mute and can't perform activities of daily living. The
a. Don't worry, Raul. You're safe here c. Flat affect patient stares out the window for hours. What is your
b. Where do you think you are? a. Possible hearing impairment d. Catatonic behavior first priority in this situation?
c. What did your family tell you? b. Family history of psychosis
d. You're at the community nursing home c. Content of the hallucination 76. The patient tells you that a "voice" keeps laughing a. Assist the patient with feeding
d. Otitis media at him and tells him he must crawl on his hands and b. Assist the patient with showering and tasks for
Situation: The police bring a patient to the emergency knees like a dog. Which of the following would be the hygiene
department. He has been locked in his apartment for the 71. A patient with schizophrenia reports that the most appropriate response? c. Reassure the patient about safely, and try to orient
past 3 days, making frequent calls to the police and newscaster on the radio has a divine message him to his surroundings
emergency services and stating that people are trying to especially for her. You would interpret this as a. "They are imaginary voices and we're here to make d. Encourage, socialization with peers, and provide a
kill him. indicating. them go, away." stimulating environment
b. "If it makes you feel better, do what the voices tell
66. A client on an inpatient psychiatric unit refuses to a. Loose of associations you." 81. Which of the following would you suspect in a
eat and states that the staff is poisoning her food. b. Delusion of reference c. "The voices can't hurt you here in the hospital" patient receiving Chlorpromazine (Thorazine) who
Which action should the nurse include in the client's c. Paranoid speech d. "Even though I don't hear the voices, I understand that complains of a sore throat and has a fever?
care plan? d. Flight of ideas you do."
a. An allergic reaction
a. Explain to the client that the staff can be trusted 72. What type of delusions is the patient experiencing? 77. A 23-year-old patient is receiving antipsychotic b. Jaundice
b. Show the client that others eat the food without harm medication to treat his schizophrenia. He's c. Dyskinesia
c. Offer the client factory-sealed foods and beverages a. Persecutory experiencing some motor abnormalities called d. Agranulocytosis
d. Institute behavioral modification with privileges b. Grandiose extrapyramidal effects. Which of the following
dependent on intake c. Jealous extrapyramidal effects occurs most frequently in 82. While providing information for the family of a
d. Somatic younger make patients? patient with schizophrenia, you should be sure to
67. The client tells the nurse that he can't eat because inform them about which of the following
his food has been poisoned. This statement is an Situation: Helen, with a diagnosis of disorganized a. Akathisia characteristics of the disorder?
indication of which of the following? schizophrenia is creating a disturbance in the day room. b. Akinesia
She is yelling and pointing at another patient, accusing c. Dystonia a. Relapse can be prevented if the patient takes
a. Paranoia him to stealing her purse. Several patients are in the day d. Pseudoparkinsonism medication
b. Delusion of persecution room when this incident starts. b. Support is available to help family members meet
c. Hallucination 78. Which of the following should you do next? their own needs
d. Illusion 73. The nurse is preparing to care for a client diagnosed c. Improvement should occur if the patient's
with catatonic schizophrenia. In anticipation of this a. Firmly redirect the patient to her room to discuss the environment is carefully maintained
68. The client on antipsychotic drugs begins to exhibit client's arrival, what should the nurse do? incident d. Stressful situations in the family in the family can
signs and symptoms of which disorder? b. Call the assistance and place the patient in locked precipitate a relapse in the patient
a. Notify security seclusion
a. Akinesia b. Prepare a magnesium sulfate drip c. Help the patient look for her purse 83. While caring for John, the nurse knows that John
b. Pseudoparkinsonism c. Place a specialty mattress overlay on the bed d. Don't intervene - the patients need a little bit of room may have trouble with:
c. Tardive dyskinesia d. Communicable the client's nothing-by-mouth status to in which to work out differences
d. Oculogyric crisis the dietary department a. Staff who are cheerful
Situation: John is admitted with a diagnosis of paranoid b. Simple direct sentences
69. During a patient history, a patient state that she 74. The nurse is caring for a client whom she suspects is schizophrenia. c. Multiple commands
used to believe she was God. But she knows this isn't paranoid. How would the nurse confirm this d. Violent behaviors
true. Which of the following would be your best assessment? 79. You're reaching a community group about
response?" schizophrenia disorders. You explain the different types 84 Which nursing diagnosis is most likely to be
a. indirect questioning of schizophrenia and delusional disorders. You also associated with a person who has a medical diagnosis
a. "Does it bother you that you used to believe that b. Direct questioning explain that, unlike schizophrenia, delusional disorders: of schizophrenia, paranoid type?
about yourself?" c. Les-ad-in-sentences
b. "Your thoughts are now more appropriate" d. Open-ended sentences a. Tend to begin in early childhood a. Fear of being along
c. "Many people have these delusions." b. Affect more men than women b. Perceptual disturbance related to delusion of
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persecution hospital stimulated her anger by using a condescending tone of

c. Social isolation related to impaired ability to trust b. Provide nutritious food and a quite place to rest 95. When preparing to conduct group therapy, the voice. Which of the following responses by the nurse
d. Impaired social skills related to inadequate developed c. Protect the client and others from harm nurse keeps in mind that the optimal number of clients would be the most therapeutic?
superego d. Create a structured environment in a group would be:
a. "I feel angry when I hear that tone of voice"
85. Which of the following behaviors can the nurse Situation: Wendell, 24 year-old student with a primary a. 6 to 8 b. "You make me so angry when you talked to me that
anticipate with this client? sleep disorder, is unable to initiate maintenance of b. 10 to 12 way."
sleep. Primary sleep disorders may be categorized as c. 3 to 5 c. "Are you trying to make me angry?"
a. Negative cognitive distortions dyssomnias or parasomnias. d. Unlimited d. "Why do you use that condescending tone of voice
b. Impaired psychomotor development with me?"
c. Delusions of grandeur and hyperactivity 91. The nurse is caring for a client who complains; of 96. What occurs during the working phase of the-nurse-
d. Alteration of appetite and sleep pattern fat?gue, inability to concentrate, and palpitations. The client relationship? 100. A 35 year-old client tells the nurse that he never
client stales that she has been experiencing these disagrees with anyone and that he has loved everyone
Situation: A client is admitted to the hospital. During the symptoms for the past 6 months. Which factor in the a. The nurse assesses the client's needs and develops a he's ever known. What would be the nurse's best
assessment the nurse notes that the client has not slept client’s history has most likely contributed to.these plan of care response to this client?
for a week. The client is talking rapidly, and throwing his symptoms? b. The nurse and client together evaluate and modify
arms around randomly. the goals of the relationship a. "How do you manage to do that?"
a. History of recent fever c. The nurse and client discuss their feelings about b. "That's hard to believe. Most people couldn't to that."
86. When writing an assessment of a client with mood b. Shift work terminating the relationship c. "What do you do with your feelings of dissatisfaction
disorder, the nurse should specify: c. Hyperthyroidism d. The nurse and client explore each other's expectations or anger?"
d. Fear of-the relationship d. "How did you come to adopt such a way of life?"
a. How flat the client's affect
b. How suicidal the client is 92. If Wendell complains of experiencing an 97. A 42 year-old homemaker arrives at the emergency
c. How grandiose the client is overwhelming urge to sleep and states that he's been department with uncomfortable crying and anxiety.
d. How the client is behaving falling asleep while studying and reports that these Her husband of 17 years has recently asked her for a
episodes occur about 5 times daily Wendell is most divorce. The patient is sitting in a chair, rocking back
87. It is an apprehensive anticipation of an unknown likely experiencing which sleep disorder? and forth. Which is the best response for the nurse to
danger: make?
a. Breathing-related sleep disorder
a. Fear b. Narcolepsy a. "You must stop crying so that we can discuss your
b. Anxiety c. Primary hypersomnia feelings about the divorce."
c. Antisocial d. Circadian rhythm disorder b. "Once you find a job, you will feel much better and
d. Schizoid more secure."
93. The nurse is preparing a teaching plan for a client c. "I can see how upset you are. Let's sit in the office so
88. It is an, emotional response to a consciously diagnosed with primary insomnia. Which of the that we can talk about how you're feeling."
recognized threat. following teaching topics should be included in the d. "Once you have a lawyer looking out for your
plan? interests, you will feel better."
a. Fear
b. Anxiety a. Eating unlimited spicy foods, and limiting caffeine and 98. A client on the unit tells the nurse that his wife's
c. Antisocial alcohol nagging really gets on his nerves. He asks the nurse if
d. Schizoid b. Exercising 1 hour before bedtime to promote sleep she will talk with his wife about nagging during their
c. Importance of steeping whenever the client tires family session tomorrow afternoon. Which of the
89. All but one is an example of situational crisis: d. Drinking warm milk before bed to induce sleep following would be most therapeutic response to
client?
a. Menstruation 94. Examples of dyssomnia includes:
b. Role changes a. "Tell me more specifically about her complaints"
c. Rape a. Insomnia, hypersomnia, narcolepsy b. "Can you think why she might nag you so much?"
d. Divorce b. Sleepwalking, nightmare c. "I'll help you think about how to bring this up
c. Snoring while sleeping yourself tomorrow."
90. What would be the highest priority in formulating a d. Non-rapid eye movement d. "Why do you want me to initiate this discussion in
nursing care plan for this client? tomorrow's session rather than you?"
Situation: The following questions refer to therapeutic
a. Isolate the client until he or she adjusts to 'the communication. 99. The nurse is working with a client who has just
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TEST I - Foundation of Professional Nursing 5. Nurse Betty is assigned to the following clients. d. “I need something stronger for pain d. Pulling the lobule down and forward
Practice The client that the nurse would see first after relief”
endorsement? 16. Which instruction should nurse Tom give to a
1. The nurse In-charge in labor and delivery unit a. A 34 year-old post-operative 10. The physician prescribes a loop diuretic for a male client who is having external radiation
administered a dose of terbutaline to a client appendectomy client of five hours who client. When administering this drug, the nurse therapy:
without checking the client’s pulse. The standard is complaining of pain. anticipates that the client may develop which a. Protect the irritated skin from sunlight.
that would be used to determine if the nurse b. A 44 year-old myocardial infarction (MI) electrolyte imbalance? b. Eat 3 to 4 hours before treatment.
was negligent is: client who is complaining of nausea. a. Hypernatremia c. Wash the skin over regularly.
a. The physician’s orders. c. A 26 year-old client admitted for b. Hyperkalemia d. Apply lotion or oil to the radiated area
b. The action of a clinical nurse specialist dehydration whose intravenous (IV) has c. Hypokalemia when it is red or sore.
who is recognized expert in the field. infiltrated. d. Hypervolemia
c. The statement in the drug literature d. A 63 year-old post operative’s 17. In assisting a female client for immediate
about administration of terbutaline. abdominal hysterectomy client of three 11. She finds out that some managers have surgery, the nurse In-charge is aware that she
d. The actions of a reasonably prudent days whose incisional dressing is benevolent-authoritative style of management. should:
nurse with similar education and saturated with serosanguinous fluid. Which of the following behaviors will she exhibit a. Encourage the client to void following
experience. most likely? preoperative medication.
6. Nurse Gail places a client in a four-point restraint a. Have condescending trust and b. Explore the client’s fears and anxieties
2. Nurse Trish is caring for a female client with a following orders from the physician. The client confidence in their subordinates. about the surgery.
history of GI bleeding, sickle cell disease, and a care plan should include: b. Gives economic and ego awards. c. Assist the client in removing dentures
platelet count of 22,000/μl. The female client is a. Assess temperature frequently. c. Communicates downward to staffs. and nail polish.
dehydrated and receiving dextrose 5% in half- b. Provide diversional activities. d. Allows decision making among d. Encourage the client to drink water prior
normal saline solution at 150 ml/hr. The client c. Check circulation every 15-30 minutes. subordinates. to surgery.
complains of severe bone pain and is scheduled d. Socialize with other patients once a shift.
to receive a dose of morphine sulfate. In 12. Nurse Amy is aware that the following is true 18. A male client is admitted and diagnosed with
administering the medication, Nurse Trish 7. A male client who has severe burns is receiving about functional nursing acute pancreatitis after a holiday celebration of
should avoid which route? H2 receptor antagonist therapy. The nurse In- a. Provides continuous, coordinated and excessive food and alcohol. Which assessment
a. I.V charge knows the purpose of this therapy is to: comprehensive nursing services. finding reflects this diagnosis?
b. I.M a. Prevent stress ulcer b. One-to-one nurse patient ratio. a. Blood pressure above normal range.
c. Oral b. Block prostaglandin synthesis c. Emphasize the use of group b. Presence of crackles in both lung fields.
d. S.C c. Facilitate protein synthesis. collaboration. c. Hyperactive bowel sounds
d. Enhance gas exchange d. Concentrates on tasks and activities. d. Sudden onset of continuous epigastric
3. Dr. Garcia writes the following order for the and back pain.
client who has been recently admitted “Digoxin 8. The doctor orders hourly urine output 13. Which type of medication order might read
.125 mg P.O. once daily.” To prevent a dosage measurement for a postoperative male client. "Vitamin K 10 mg I.M. daily × 3 days?" 19. Which dietary guidelines are important for nurse
error, how should the nurse document this order The nurse Trish records the following amounts of a. Single order Oliver to implement in caring for the client with
onto the medication administration record? output for 2 consecutive hours: 8 a.m.: 50 ml; 9 b. Standard written order burns?
a. “Digoxin .1250 mg P.O. once daily” a.m.: 60 ml. Based on these amounts, which c. Standing order a. Provide high-fiber, high-fat diet
b. “Digoxin 0.1250 mg P.O. once daily” action should the nurse take? d. Stat order b. Provide high-protein, high-carbohydrate
c. “Digoxin 0.125 mg P.O. once daily” a. Increase the I.V. fluid infusion rate diet.
d. “Digoxin .125 mg P.O. once daily” b. Irrigate the indwelling urinary catheter 14. A female client with a fecal impaction frequently c. Monitor intake to prevent weight gain.
c. Notify the physician exhibits which clinical manifestation? d. Provide ice chips or water intake.
4. A newly admitted female client was diagnosed d. Continue to monitor and record hourly a. Increased appetite
with deep vein thrombosis. Which nursing urine output b. Loss of urge to defecate 20. Nurse Hazel will administer a unit of whole
diagnosis should receive the highest priority? c. Hard, brown, formed stools blood, which priority information should the
a. Ineffective peripheral tissue perfusion 9. Tony, a basketball player twist his right ankle d. Liquid or semi-liquid stools nurse have about the client?
related to venous congestion. while playing on the court and seeks care for a. Blood pressure and pulse rate.
b. Risk for injury related to edema. ankle pain and swelling. After the nurse applies 15. Nurse Linda prepares to perform an otoscopic b. Height and weight.
c. Excess fluid volume related to peripheral ice to the ankle for 30 minutes, which statement examination on a female client. For proper c. Calcium and potassium levels
vascular disease. by Tony suggests that ice application has been visualization, the nurse should position the d. Hgb and Hct levels.
d. Impaired gas exchange related to effective? client's ear by: 21. Nurse Michelle witnesses a female client sustain
increased blood flow. a. “My ankle looks less swollen now”. a. Pulling the lobule down and back a fall and suspects that the leg may be broken.
b. “My ankle feels warm”. b. Pulling the helix up and forward The nurse takes which priority action?
c. “My ankle appears redder now”. c. Pulling the helix up and back a. Takes a set of vital signs.
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b. Call the radiology department for X-ray. c. 1.5 cc d. Planning and goals “Meperidine, 100 mg/ml.” How many milliliters
c. Reassure the client that everything will d. 2.5 cc of meperidine should the client receive?
be alright. 32. Which of the following item is considered the a. 0.75
d. Immobilize the leg before moving the 27. A child of 10 years old is to receive 400 cc of IV single most important factor in assisting the b. 0.6
client. fluid in an 8 hour shift. The IV drip factor is 60. health professional in arriving at a diagnosis or c. 0.5
The IV rate that will deliver this amount is: determining the person’s needs? d. 0.25
22. A male client is being transferred to the nursing a. 50 cc/ hour a. Diagnostic test results
unit for admission after receiving a radium b. 55 cc/ hour b. Biographical date 38. A male client with diabetes mellitus is receiving
implant for bladder cancer. The nurse in-charge c. 24 cc/ hour c. History of present illness insulin. Which statement correctly describes an
would take which priority action in the care of d. 66 cc/ hour d. Physical examination insulin unit?
this client? a. It’s a common measurement in the
a. Place client on reverse isolation. 28. The nurse is aware that the most important 33. In preventing the development of an external metric system.
b. Admit the client into a private room. nursing action when a client returns from rotation deformity of the hip in a client who b. It’s the basis for solids in the avoirdupois
c. Encourage the client to take frequent surgery is: must remain in bed for any period of time, the system.
rest periods. a. Assess the IV for type of fluid and rate of most appropriate nursing action would be to c. It’s the smallest measurement in the
d. Encourage family and friends to visit. flow. use: apothecary system.
b. Assess the client for presence of pain. a. Trochanter roll extending from the crest d. It’s a measure of effect, not a standard
23. A newly admitted female client was diagnosed c. Assess the Foley catheter for patency of the ileum to the mid-thigh. measure of weight or quantity.
with agranulocytosis. The nurse formulates and urine output b. Pillows under the lower legs.
which priority nursing diagnosis? d. Assess the dressing for drainage. c. Footboard 39. Nurse Oliver measures a client’s temperature at
a. Constipation d. Hip-abductor pillow 102° F. What is the equivalent Centigrade
b. Diarrhea 29. Which of the following vital sign assessments temperature?
c. Risk for infection that may indicate cardiogenic shock after 34. Which stage of pressure ulcer development does a. 40.1 °C
d. Deficient knowledge myocardial infarction? the ulcer extend into the subcutaneous tissue? b. 38.9 °C
a. BP – 80/60, Pulse – 110 irregular a. Stage I c. 48 °C
24. A male client is receiving total parenteral b. BP – 90/50, Pulse – 50 regular b. Stage II d. 38 °C
nutrition suddenly demonstrates signs and c. BP – 130/80, Pulse – 100 regular c. Stage III 40. The nurse is assessing a 48-year-old client who
symptoms of an air embolism. What is the d. BP – 180/100, Pulse – 90 irregular d. Stage IV has come to the physician’s office for his annual
priority action by the nurse? physical exam. One of the first physical signs of
a. Notify the physician. 30. Which is the most appropriate nursing action in 35. When the method of wound healing is one in aging is:
b. Place the client on the left side in the obtaining a blood pressure measurement? which wound edges are not surgically a. Accepting limitations while developing
Trendelenburg position. a. Take the proper equipment, place the approximated and integumentary continuity is assets.
c. Place the client in high-Fowlers position. client in a comfortable position, and restored by granulations, the wound healing is b. Increasing loss of muscle tone.
d. Stop the total parenteral nutrition. record the appropriate information in termed c. Failing eyesight, especially close vision.
the client’s chart. a. Second intention healing d. Having more frequent aches and pains.
25. Nurse May attends an educational conference b. Measure the client’s arm, if you are not b. Primary intention healing
on leadership styles. The nurse is sitting with a sure of the size of cuff to use. c. Third intention healing 41. The physician inserts a chest tube into a female
nurse employed at a large trauma center who c. Have the client recline or sit comfortably d. First intention healing client to treat a pneumothorax. The tube is
states that the leadership style at the trauma in a chair with the forearm at the level of connected to water-seal drainage. The nurse in-
center is task-oriented and directive. The nurse the heart. 36. An 80-year-old male client is admitted to the charge can prevent chest tube air leaks by:
determines that the leadership style used at the d. Document the measurement, which hospital with a diagnosis of pneumonia. Nurse a. Checking and taping all connections.
trauma center is: extremity was used, and the position Oliver learns that the client lives alone and b. Checking patency of the chest tube.
a. Autocratic. that the client was in during the hasn’t been eating or drinking. When assessing c. Keeping the head of the bed slightly
b. Laissez-faire. measurement. him for dehydration, nurse Oliver would expect elevated.
c. Democratic. to find: d. Keeping the chest drainage system
d. Situational 31. Asking the questions to determine if the person a. Hypothermia below the level of the chest.
26. The physician orders DS 500 cc with KCl 10 understands the health teaching provided by the b. Hypertension
mEq/liter at 30 cc/hr. The nurse in-charge is nurse would be included during which step of c. Distended neck veins 42. Nurse Trish must verify the client’s identity
going to hang a 500 cc bag. KCl is supplied 20 the nursing process? d. Tachycardia before administering medication. She is aware
mEq/10 cc. How many cc’s of KCl will be added that the safest way to verify identity is to:
to the IV solution? a. Assessment 37. The physician prescribes meperidine (Demerol), a. Check the client’s identification band.
a. .5 cc b. Evaluation 75 mg I.M. every 4 hours as needed, to control a b. Ask the client to state his name.
b. 5 cc c. Implementation client’s postoperative pain. The package insert is
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c. State the client’s name out loud and c. Every 2 years d. Hypercalcemia d. Obtaining the specimen from the urinary
wait a client to repeat it. d. Once, to establish baseline drainage bag.
d. Check the room number and the client’s 54. Nurse Len is administering sublingual nitrglycerin
name on the bed. 49. A male client has the following arterial blood gas (Nitrostat) to the newly admitted client. 59. Nurse Meredith is in the process of giving a
values: pH 7.30; Pao2 89 mmHg; Paco2 50 Immediately afterward, the client may client a bed bath. In the middle of the
43. The physician orders dextrose 5 % in water, mmHg; and HCO3 26mEq/L. Based on these experience: procedure, the unit secretary calls the nurse on
1,000 ml to be infused over 8 hours. The I.V. values, Nurse Patricia should expect which a. Throbbing headache or dizziness the intercom to tell the nurse that there is an
tubing delivers 15 drops/ml. Nurse John should condition? b. Nervousness or paresthesia. emergency phone call. The appropriate nursing
run the I.V. infusion at a rate of: a. Respiratory acidosis c. Drowsiness or blurred vision. action is to:
a. 30 drops/minute b. Respiratory alkalosis d. Tinnitus or diplopia. a. Immediately walk out of the client’s
b. 32 drops/minute c. Metabolic acidosis room and answer the phone call.
c. 20 drops/minute d. Metabolic alkalosis b. Cover the client, place the call light
d. 18 drops/minute 55. Nurse Michelle hears the alarm sound on the within reach, and answer the phone call.
50. Nurse Len refers a female client with terminal telemetry monitor. The nurse quickly looks at c. Finish the bed bath before answering
44. If a central venous catheter becomes cancer to a local hospice. What is the goal of this the monitor and notes that a client is in a the phone call.
disconnected accidentally, what should the referral? ventricular tachycardia. The nurse rushes to the d. Leave the client’s door open so the client
nurse in-charge do immediately? a. To help the client find appropriate client’s room. Upon reaching the client’s can be monitored and the nurse can
a. Clamp the catheter treatment options. bedside, the nurse would take which action answer the phone call.
b. Call another nurse b. To provide support for the client and first?
c. Call the physician family in coping with terminal illness. a. Prepare for cardioversion 60. Nurse Janah is collecting a sputum specimen for
d. Apply a dry sterile dressing to the site. c. To ensure that the client gets counseling b. Prepare to defibrillate the client culture and sensitivity testing from a client who
regarding health care costs. c. Call a code has a productive cough. Nurse Janah plans to
45. A female client was recently admitted. She has d. To teach the client and family about d. Check the client’s level of consciousness implement which intervention to obtain the
fever, weight loss, and watery diarrhea is being cancer and its treatment. specimen?
admitted to the facility. While assessing the 56. Nurse Hazel is preparing to ambulate a female a. Ask the client to expectorate a small
client, Nurse Hazel inspects the client’s abdomen 51. When caring for a male client with a 3-cm stage I client. The best and the safest position for the amount of sputum into the emesis basin.
and notice that it is slightly concave. Additional pressure ulcer on the coccyx, which of the nurse in assisting the client is to stand: b. Ask the client to obtain the specimen
assessment should proceed in which order: following actions can the nurse institute a. On the unaffected side of the client. after breakfast.
a. Palpation, auscultation, and percussion. independently? b. On the affected side of the client. c. Use a sterile plastic container for
b. Percussion, palpation, and auscultation. a. Massaging the area with an astringent c. In front of the client. obtaining the specimen.
c. Palpation, percussion, and auscultation. every 2 hours. d. Behind the client. d. Provide tissues for expectoration and
d. Auscultation, percussion, and palpation. b. Applying an antibiotic cream to the area obtaining the specimen.
three times per day. 57. Nurse Janah is monitoring the ongoing care
46. Nurse Betty is assessing tactile fremitus in a c. Using normal saline solution to clean the given to the potential organ donor who has been 61. Nurse Ron is observing a male client using a
client with pneumonia. For this examination, ulcer and applying a protective dressing diagnosed with brain death. The nurse walker. The nurse determines that the client is
nurse Betty should use the: as necessary. determines that the standard of care had been using the walker correctly if the client:
a. Fingertips d. Using a povidone-iodine wash on the maintained if which of the following data is a. Puts all the four points of the walker flat
b. Finger pads ulceration three times per day. observed? on the floor, puts weight on the hand
c. Dorsal surface of the hand 52. Nurse Oliver must apply an elastic bandage to a a. Urine output: 45 ml/hr pieces, and then walks into it.
d. Ulnar surface of the hand client’s ankle and calf. He should apply the b. Capillary refill: 5 seconds b. Puts weight on the hand pieces, moves
bandage beginning at the client’s: c. Serum pH: 7.32 the walker forward, and then walks into
47. Which type of evaluation occurs continuously a. Knee d. Blood pressure: 90/48 mmHg it.
throughout the teaching and learning process? b. Ankle c. Puts weight on the hand pieces, slides
a. Summative c. Lower thigh 58. Nurse Amy has an order to obtain a urinalysis the walker forward, and then walks into
b. Informative d. Foot from a male client with an indwelling urinary it.
c. Formative catheter. The nurse avoids which of the d. Walks into the walker, puts weight on
d. Retrospective 53. A 10 year old child with type 1 diabetes develops following, which contaminate the specimen? the hand pieces, and then puts all four
48. A 45 year old client, has no family history of diabetic ketoacidosis and receives a continuous a. Wiping the port with an alcohol swab points of the walker flat on the floor.
breast cancer or other risk factors for this insulin infusion. Which condition represents the before inserting the syringe.
disease. Nurse John should instruct her to have greatest risk to this child? b. Aspirating a sample from the port on the 62. Nurse Amy has documented an entry regarding
mammogram how often? a. Hypernatremia drainage bag. client care in the client’s medical record. When
a. Twice per year b. Hypokalemia c. Clamping the tubing of the drainage bag. checking the entry, the nurse realizes that
b. Once per year c. Hyperphosphatemia
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incorrect information was documented. How a. Prone with head turned toward the side d. Post-test only design d. Will remain unable to practice
does the nurse correct this error? supported by a pillow. professional nursing
a. Erases the error and writes in the correct b. Sims’ position with the head of the bed 72. Cherry notes down ideas that were derived from
information. flat. the description of an investigation written by the 77. Ronald plans to conduct a research on the use of
b. Uses correction fluid to cover up the c. Right side-lying with the head of the bed person who conducted it. Which type of a new method of pain assessment scale. Which
incorrect information and writes in the elevated 45 degrees. reference source refers to this? of the following is the second step in the
correct information. d. Left side-lying with the head of the bed a. Footnote conceptualizing phase of the research process?
c. Draws one line to cross out the incorrect elevated 45 degrees. b. Bibliography a. Formulating the research hypothesis
information and then initials the change. c. Primary source b. Review related literature
d. Covers up the incorrect information 67. Nurse John develops methods for data d. Endnotes c. Formulating and delimiting the research
completely using a black pen and writes gathering. Which of the following criteria of a problem
in the correct information good instrument refers to the ability of the 73. When Nurse Trish is providing care to his d. Design the theoretical and conceptual
instrument to yield the same results upon its patient, she must remember that her duty is framework
63. Nurse Ron is assisting with transferring a client repeated administration? bound not to do doing any action that will cause
from the operating room table to a stretcher. To a. Validity the patient harm. This is the meaning of the 78. The leader of the study knows that certain
provide safety to the client, the nurse should: b. Specificity bioethical principle: patients who are in a specialized research setting
a. Moves the client rapidly from the table c. Sensitivity a. Non-maleficence tend to respond psychologically to the
to the stretcher. d. Reliability b. Beneficence conditions of the study. This referred to as :
b. Uncovers the client completely before c. Justice a. Cause and effect
transferring to the stretcher. 68. Harry knows that he has to protect the rights of d. Solidarity b. Hawthorne effect
c. Secures the client safety belts after human research subjects. Which of the following c. Halo effect
transferring to the stretcher. actions of Harry ensures anonymity? 74. When a nurse in-charge causes an injury to a d. Horns effect
d. Instructs the client to move self from the a. Keep the identities of the subject secret female patient and the injury caused becomes
table to the stretcher. b. Obtain informed consent the proof of the negligent act, the presence of 79. Mary finally decides to use judgment sampling
c. Provide equal treatment to all the the injury is said to exemplify the principle of: on her research. Which of the following actions
64. Nurse Myrna is providing instructions to a subjects of the study. a. Force majeure of is correct?
nursing assistant assigned to give a bed bath to a d. Release findings only to the participants b. Respondeat superior a. Plans to include whoever is there during
client who is on contact precautions. Nurse of the study c. Res ipsa loquitor his study.
Myrna instructs the nursing assistant to use d. Holdover doctrine b. Determines the different nationality of
which of the following protective items when 69. Patient’s refusal to divulge information is a patients frequently admitted and
giving bed bath? limitation because it is beyond the control of 75. Nurse Myrna is aware that the Board of Nursing decides to get representations samples
a. Gown and goggles Tifanny”. What type of research is appropriate has quasi-judicial power. An example of this from each.
b. Gown and gloves for this study? power is: c. Assigns numbers for each of the
c. Gloves and shoe protectors a. Descriptive- correlational a. The Board can issue rules and patients, place these in a fishbowl and
d. Gloves and goggles b. Experiment regulations that will govern the practice draw 10 from it.
c. Quasi-experiment of nursing d. Decides to get 20 samples from the
65. Nurse Oliver is caring for a client with impaired d. Historical b. The Board can investigate violations of admitted patients
mobility that occurred as a result of a stroke. The the nursing law and code of ethics
client has right sided arm and leg weakness. The 70. Nurse Ronald is aware that the best tool for data c. The Board can visit a school applying for 80. The nursing theorist who developed
nurse would suggest that the client use which of gathering is? a permit in collaboration with CHED transcultural nursing theory is:
the following assistive devices that would a. Interview schedule d. The Board prepares the board a. Florence Nightingale
provide the best stability for ambulating? b. Questionnaire examinations b. Madeleine Leininger
a. Crutches c. Use of laboratory data c. Albert Moore
b. Single straight-legged cane d. Observation 76. When the license of nurse Krina is revoked, it d. Sr. Callista Roy
c. Quad cane means that she:
d. Walker 71. Monica is aware that there are times when only a. Is no longer allowed to practice the 81. Marion is aware that the sampling method that
manipulation of study variables is possible and profession for the rest of her life gives equal chance to all units in the population
66. A male client with a right pleural effusion noted the elements of control or randomization are b. Will never have her/his license re-issued to get picked is:
on a chest X-ray is being prepared for not attendant. Which type of research is since it has been revoked a. Random
thoracentesis. The client experiences severe referred to this? c. May apply for re-issuance of his/her b. Accidental
dizziness when sitting upright. To provide a safe a. Field study license based on certain conditions c. Quota
environment, the nurse assists the client to b. Quasi-experiment stipulated in RA 9173 d. Judgment
which position for the procedure? c. Solomon-Four group design
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82. John plans to use a Likert Scale to his study to d. Assessing the client’s vital signs when d. 30 minutes after administering the next
determine the: 89. Nurse Marian is preparing to administer a blood the transfusion ends. dose.
a. Degree of agreement and disagreement transfusion. Which action should the nurse take
b. Compliance to expected standards first? 94. A male client complains of abdominal discomfort 99. Nurse May is aware that the main advantage of
c. Level of satisfaction a. Arrange for typing and cross matching of and nausea while receiving tube feedings. Which using a floor stock system is:
d. Degree of acceptance the client’s blood. intervention is most appropriate for this a. The nurse can implement medication
b. Compare the client’s identification problem? orders quickly.
83. Which of the following theory addresses the four wristband with the tag on the unit of a. Give the feedings at room temperature. b. The nurse receives input from the
modes of adaptation? blood. b. Decrease the rate of feedings and the pharmacist.
a. Madeleine Leininger c. Start an I.V. infusion of normal saline concentration of the formula. c. The system minimizes transcription
b. Sr. Callista Roy solution. c. Place the client in semi-Fowler's position errors.
c. Florence Nightingale d. Measure the client’s vital signs. while feeding. d. The system reinforces accurate
d. Jean Watson d. Change the feeding container every 12 calculations.
90. A 65 years old male client requests his hours.
84. Ms. Garcia is responsible to the number of medication at 9 p.m. instead of 10 p.m. so that 100. Nurse Oliver is assessing a client's abdomen.
personnel reporting to her. This principle refers he can go to sleep earlier. Which type of nursing 95. Nurse Patricia is reconstituting a powdered Which finding should the nurse report as
to: intervention is required? medication in a vial. After adding the solution to abnormal?
a. Span of control a. Independent the powder, she nurse should: a. Dullness over the liver.
b. Unity of command b. Dependent a. Do nothing. b. Bowel sounds occurring every 10
c. Downward communication c. Interdependent b. Invert the vial and let it stand for 3 to 5 seconds.
d. Leader d. Intradependent minutes. c. Shifting dullness over the abdomen.
c. Shake the vial vigorously. d. Vascular sounds heard over the renal
85. Ensuring that there is an informed consent on 91. A female client is to be discharged from an acute d. Roll the vial gently between the palms. arteries.
the part of the patient before a surgery is done, care facility after treatment for right leg
illustrates the bioethical principle of: thrombophlebitis. The Nurse Betty notes that 96. Which intervention should the nurse Trish use
a. Beneficence the client's leg is pain-free, without redness or when administering oxygen by face mask to a
b. Autonomy edema. The nurse's actions reflect which step of female client?
c. Veracity the nursing process? a. Secure the elastic band tightly around
d. Non-maleficence a. Assessment the client's head.
b. Diagnosis b. Assist the client to the semi-Fowler
86. Nurse Reese is teaching a female client with c. Implementation position if possible.
peripheral vascular disease about foot care; d. Evaluation c. Apply the face mask from the client's
Nurse Reese should include which instruction? chin up over the nose.
a. Avoid wearing cotton socks. 92. Nursing care for a female client includes d. Loosen the connectors between the
b. Avoid using a nail clipper to cut toenails. removing elastic stockings once per day. The oxygen equipment and humidifier.
c. Avoid wearing canvas shoes. Nurse Betty is aware that the rationale for this
d. Avoid using cornstarch on feet. intervention? 97. The maximum transfusion time for a unit of
a. To increase blood flow to the heart packed red blood cells (RBCs) is:
87. A client is admitted with multiple pressure b. To observe the lower extremities a. 6 hours
ulcers. When developing the client's diet plan, c. To allow the leg muscles to stretch and b. 4 hours
the nurse should include: relax c. 3 hours
a. Fresh orange slices d. To permit veins in the legs to fill with d. 2 hours
b. Steamed broccoli blood.
c. Ice cream 98. Nurse Monique is monitoring the effectiveness
d. Ground beef patties 93. Which nursing intervention takes highest priority of a client's drug therapy. When should the
when caring for a newly admitted client who's nurse Monique obtain a blood sample to
88. The nurse prepares to administer a cleansing receiving a blood transfusion? measure the trough drug level?
enema. What is the most common client a. Instructing the client to report any a. 1 hour before administering the next
position used for this procedure? itching, swelling, or dyspnea. dose.
a. Lithotomy b. Informing the client that the transfusion b. Immediately before administering the
b. Supine usually take 1 ½ to 2 hours. next dose.
c. Prone c. Documenting blood administration in c. Immediately after administering the
d. Sims’ left lateral the client care record. next dose.
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Answers and Rationale – Foundation of The best treatment for this prophylactic use of Rationale: To perform an otoscopic Rationale: Agranulocytosis is characterized by
Professional Nursing Practice antacids and H2 receptor blockers. examination on an adult, the nurse grasps the a reduced number of leukocytes (leucopenia)
8. Answer: (D) Continue to monitor and record helix of the ear and pulls it up and back to and neutrophils (neutropenia) in the blood.
1. Answer: (D) The actions of a reasonably prudent hourly urine output straighten the ear canal. For a child, the nurse The client is at high risk for infection because
nurse with similar education and experience. Rationale: Normal urine output for an adult is grasps the helix and pulls it down to straighten of the decreased body defenses against
Rationale: The standard of care is determined approximately 1 ml/minute (60 ml/hour). the ear canal. Pulling the lobule in any microorganisms. Deficient knowledge related
by the average degree of skill, care, and Therefore, this client's output is normal. direction wouldn't straighten the ear canal for to the nature of the disorder may be
diligence by nurses in similar circumstances. Beyond continued evaluation, no nursing visualization. appropriate diagnosis but is not the priority.
2. Answer: (B) I.M action is warranted. 16. Answer: (A) Protect the irritated skin from 24. Answer: (B) Place the client on the left side in
Rationale: With a platelet count of 22,000/μl, 9. Answer: (B) “My ankle feels warm”. sunlight. the Trendelenburg position.
the clients tends to bleed easily. Therefore, Rationale: Ice application decreases pain and Rationale: Irradiated skin is very sensitive and Rationale: Lying on the left side may prevent
the nurse should avoid using the I.M. route swelling. Continued or increased pain, redness, must be protected with clothing or sunblock. air from flowing into the pulmonary veins. The
because the area is a highly vascular and can and increased warmth are signs of The priority approach is the avoidance of Trendelenburg position increases intrathoracic
bleed readily when penetrated by a needle. inflammation that shouldn't occur after ice strong sunlight. pressure, which decreases the amount of
The bleeding can be difficult to stop. application 17. Answer: (C) Assist the client in removing blood pulled into the vena cava during
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” 10. Answer: (B) Hyperkalemia dentures and nail polish. aspiration.
Rationale: The nurse should always place a Rationale: A loop diuretic removes water and, Rationale: Dentures, hairpins, and combs must 25. Answer: (A) Autocratic.
zero before a decimal point so that no one along with it, sodium and potassium. This may be removed. Nail polish must be removed so Rationale: The autocratic style of leadership is
misreads the figure, which could result in a result in hypokalemia, hypovolemia, and that cyanosis can be easily monitored by a task-oriented and directive.
dosage error. The nurse should never insert a hyponatremia. observing the nail beds. 26. Answer: (D) 2.5 cc
zero at the end of a dosage that includes a 11. Answer:(A) Have condescending trust and 18. Answer: (D) Sudden onset of continuous Rationale: 2.5 cc is to be added, because only a
decimal point because this could be misread, confidence in their subordinates epigastric and back pain. 500 cc bag of solution is being medicated
possibly leading to a tenfold increase in the Rationale: Benevolent-authoritative managers Rationale: The autodigestion of tissue by the instead of a 1 liter.
dosage. pretentiously show their trust and confidence pancreatic enzymes results in pain from 27. Answer: (A) 50 cc/ hour
4. Answer: (A) Ineffective peripheral tissue to their followers. inflammation, edema, and possible Rationale: A rate of 50 cc/hr. The child is to
perfusion related to venous congestion. 12. Answer: (A) Provides continuous, coordinated hemorrhage. Continuous, unrelieved epigastric receive 400 cc over a period of 8 hours = 50
Rationale: Ineffective peripheral tissue and comprehensive nursing services. or back pain reflects the inflammatory process cc/hr.
perfusion related to venous congestion takes Rationale: Functional nursing is focused on in the pancreas. 28. Answer: (B) Assess the client for presence of
the highest priority because venous tasks and activities and not on the care of the 19. Answer: (B) Provide high-protein, high- pain.
inflammation and clot formation impede blood patients. carbohydrate diet. Rationale: Assessing the client for pain is a
flow in a client with deep vein thrombosis. 13. Answer: (B) Standard written order Rationale: A positive nitrogen balance is very important measure. Postoperative pain is
5. Answer: (B) A 44 year-old myocardial Rationale: This is a standard written order. important for meeting metabolic needs, tissue an indication of complication. The nurse
infarction (MI) client who is complaining of Prescribers write a single order for repair, and resistance to infection. Caloric should also assess the client for pain to
nausea. medications given only once. A stat order is goals may be as high as 5000 calories per day. provide for the client’s comfort.
Rationale: Nausea is a symptom of impending written for medications given immediately for 20. Answer: (A) Blood pressure and pulse rate. 29. Answer: (A) BP – 80/60, Pulse – 110 irregular
myocardial infarction (MI) and should be an urgent client problem. A standing order, Rationale: The baseline must be established to Rationale: The classic signs of cardiogenic
assessed immediately so that treatment can also known as a protocol, establishes recognize the signs of an anaphylactic or shock are low blood pressure, rapid and weak
be instituted and further damage to the heart guidelines for treating a particular disease or hemolytic reaction to the transfusion. irregular pulse, cold, clammy skin, decreased
is avoided. set of symptoms in special care areas such as 21. Answer: (D) Immobilize the leg before moving urinary output, and cerebral hypoxia.
6. Answer: (C) Check circulation every 15-30 the coronary care unit. Facilities also may the client. 30. Answer: (A) Take the proper equipment, place
minutes. institute medication protocols that specifically Rationale: If the nurse suspects a fracture, the client in a comfortable position, and
Rationale: Restraints encircle the limbs, which designate drugs that a nurse may not give. splinting the area before moving the client is record the appropriate information in the
place the client at risk for circulation being 14. Answer: (D) Liquid or semi-liquid stools imperative. The nurse should call for client’s chart.
restricted to the distal areas of the Rationale: Passage of liquid or semi-liquid emergency help if the client is not hospitalized Rationale: It is a general or comprehensive
extremities. Checking the client’s circulation stools results from seepage of unformed and call for a physician for the hospitalized statement about the correct procedure, and it
every 15-30 minutes will allow the nurse to bowel contents around the impacted stool in client. includes the basic ideas which are found in the
adjust the restraints before injury from the rectum. Clients with fecal impaction don't 22. Answer: (B) Admit the client into a private other options
decreased blood flow occurs. pass hard, brown, formed stools because the room. 31. Answer: (B) Evaluation
7. Answer: (A) Prevent stress ulcer feces can't move past the impaction. These Rationale: The client who has a radiation Rationale: Evaluation includes observing the
Rationale: Curling’s ulcer occurs as a clients typically report the urge to defecate implant is placed in a private room and has a person, asking questions, and comparing the
generalized stress response in burn patients. (although they can't pass stool) and a limited number of visitors. This reduces the patient’s behavioral responses with the
This results in a decreased production of decreased appetite. exposure of others to the radiation. expected outcomes.
mucus and increased secretion of gastric acid. 15. Answer: (C) Pulling the helix up and back 23. Answer: (C) Risk for infection 32. Answer: (C) History of present illness
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Rationale: The history of present illness is the 41. Answer: (A) Checking and taping all thrills, and vocal vibrations through the chest Rationale: An elastic bandage should be
single most important factor in assisting the connections wall. The fingertips and finger pads best applied form the distal area to the proximal
health professional in arriving at a diagnosis or Rationale: Air leaks commonly occur if the distinguish texture and shape. The dorsal area. This method promotes venous return. In
determining the person’s needs. system isn’t secure. Checking all connections surface best feels warmth. this case, the nurse should begin applying the
33. Answer: (A) Trochanter roll extending from the and taping them will prevent air leaks. The 47. Answer: (C) Formative bandage at the client’s foot. Beginning at the
crest of the ileum to the mid-thigh. chest drainage system is kept lower to Rationale: Formative (or concurrent) ankle, lower thigh, or knee does not promote
Rationale: A trochanter roll, properly placed, promote drainage – not to prevent leaks. evaluation occurs continuously throughout the venous return.
provides resistance to the external rotation of 42. Answer: (A) Check the client’s identification teaching and learning process. One benefit is 53. Answer: (B) Hypokalemia
the hip. band. that the nurse can adjust teaching strategies Rationale: Insulin administration causes
34. Answer: (C) Stage III Rationale: Checking the client’s identification as necessary to enhance learning. Summative, glucose and potassium to move into the cells,
Rationale: Clinically, a deep crater or without band is the safest way to verify a client’s or retrospective, evaluation occurs at the causing hypokalemia.
undermining of adjacent tissue is noted. identity because the band is assigned on conclusion of the teaching and learning 54. Answer: (A) Throbbing headache or dizziness
35. Answer: (A) Second intention healing admission and isn’t be removed at any time. (If session. Informative is not a type of Rationale: Headache and dizziness often occur
Rationale: When wounds dehisce, they will it is removed, it must be replaced). Asking the evaluation. when nitroglycerin is taken at the beginning of
allowed to heal by secondary Intention client’s name or having the client repeated his 48. Answer: (B) Once per year therapy. However, the client usually develops
36. Answer: (D) Tachycardia name would be appropriate only for a client Rationale: Yearly mammograms should begin tolerance
Rationale: With an extracellular fluid or plasma who’s alert, oriented, and able to understand at age 40 and continue for as long as the 55. Answer: (D) Check the client’s level of
volume deficit, compensatory mechanisms what is being said, but isn’t the safe standard woman is in good health. If health risks, such consciousness
stimulate the heart, causing an increase in of practice. Names on bed aren’t always as family history, genetic tendency, or past Rationale: Determining unresponsiveness is
heart rate. reliable breast cancer, exist, more frequent the first step assessment action to take. When
37. Answer: (A) 0.75 43. Answer: (B) 32 drops/minute examinations may be necessary. a client is in ventricular tachycardia, there is a
Rationale: To determine the number of Rationale: Giving 1,000 ml over 8 hours is the 49. Answer: (A) Respiratory acidosis significant decrease in cardiac output.
milliliters the client should receive, the nurse same as giving 125 ml over 1 hour (60 Rationale: The client has a below-normal However, checking the unresponsiveness
uses the fraction method in the following minutes). Find the number of milliliters per (acidic) blood pH value and an above-normal ensures whether the client is affected by the
equation. minute as follows: partial pressure of arterial carbon dioxide decreased cardiac output.
75 mg/X ml = 100 mg/1 ml 125/60 minutes = X/1 minute (Paco2) value, indicating respiratory acidosis. 56. Answer: (B) On the affected side of the client.
To solve for X, cross-multiply: 60X = 125 = 2.1 ml/minute In respiratory alkalosis, the pH value is above Rationale: When walking with clients, the
75 mg x 1 ml = X ml x 100 mg To find the number of drops per minute: normal and in the Paco2 value is below nurse should stand on the affected side and
75 = 100X 2.1 ml/X gtt = 1 ml/ 15 gtt normal. In metabolic acidosis, the pH and grasp the security belt in the midspine area of
75/100 = X X = 32 gtt/minute, or 32 drops/minute bicarbonate (Hco3) values are below normal. the small of the back. The nurse should
0.75 ml (or ¾ ml) = X 44. Answer: (A) Clamp the catheter In metabolic alkalosis, the pH and Hco3 values position the free hand at the shoulder area so
38. Answer: (D) it’s a measure of effect, not a Rationale: If a central venous catheter are above normal. that the client can be pulled toward the nurse
standard measure of weight or quantity. becomes disconnected, the nurse should 50. Answer: (B) To provide support for the client in the event that there is a forward fall. The
Rationale: An insulin unit is a measure of immediately apply a catheter clamp, if and family in coping with terminal illness. client is instructed to look up and outward
effect, not a standard measure of weight or available. If a clamp isn’t available, the nurse Rationale: Hospices provide supportive care rather than at his or her feet.
quantity. Different drugs measured in units can place a sterile syringe or catheter plug in for terminally ill clients and their families. 57. Answer: (A) Urine output: 45 ml/hr
may have no relationship to one another in the catheter hub. After cleaning the hub with Hospice care doesn’t focus on counseling Rationale: Adequate perfusion must be
quality or quantity. alcohol or povidone-iodine solution, the nurse regarding health care costs. Most client maintained to all vital organs in order for the
39. Answer: (B) 38.9 °C must replace the I.V. extension and restart the referred to hospices have been treated for client to remain visible as an organ donor. A
Rationale: To convert Fahrenheit degreed to infusion. their disease without success and will receive urine output of 45 ml per hour indicates
Centigrade, use this formula 45. Answer: (D) Auscultation, percussion, and only palliative care in the hospice. adequate renal perfusion. Low blood pressure
°C = (°F – 32) ÷ 1.8 palpation. 51. Answer: (C) Using normal saline solution to and delayed capillary refill time are circulatory
°C = (102 – 32) ÷ 1.8 Rationale: The correct order of assessment for clean the ulcer and applying a protective system indicators of inadequate perfusion. A
°C = 70 ÷ 1.8 examining the abdomen is inspection, dressing as necessary. serum pH of 7.32 is acidotic, which adversely
°C = 38.9 auscultation, percussion, and palpation. The Rationale: Washing the area with normal affects all body tissues.
40. Answer: (C) Failing eyesight, especially close reason for this approach is that the less saline solution and applying a protective 58. Answer: (D ) Obtaining the specimen from the
vision. intrusive techniques should be performed dressing are within the nurse’s realm of urinary drainage bag.
Rationale: Failing eyesight, especially close before the more intrusive techniques. interventions and will protect the area. Using a Rationale: A urine specimen is not taken from
vision, is one of the first signs of aging in Percussion and palpation can alter natural povidone-iodine wash and an antibiotic cream the urinary drainage bag. Urine undergoes
middle life (ages 46 to 64). More frequent findings during auscultation. require a physician’s order. Massaging with an chemical changes while sitting in the bag and
aches and pains begin in the early late years 46. Answer: (D) Ulnar surface of the hand astringent can further damage the skin. does not necessarily reflect the current client
(ages 65 to 79). Increase in loss of muscle tone Rationale: The nurse uses the ulnar surface, or 52. Answer: (D) Foot status. In addition, it may become
occurs in later years (age 80 and older). ball, of the hand to assess tactile fremitus,
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contaminated with bacteria from opening the the stretcher, the client is still affected by the measurements, hence laboratory data is observed. They performed differently because
system. effects of the anesthesia; therefore, the client essential. they were under observation.
59. Answer: (B) Cover the client, place the call should not move self. Safety belts can prevent 71. Answer: (B) Quasi-experiment 79. Answer: (B) Determines the different
light within reach, and answer the phone call. the client from falling off the stretcher. Rationale: Quasi-experiment is done when nationality of patients frequently admitted and
Rationale: Because telephone call is an 64. Answer: (B) Gown and gloves randomization and control of the variables are decides to get representations samples from
emergency, the nurse may need to answer it. Rationale: Contact precautions require the use not possible. each.
The other appropriate action is to ask another of gloves and a gown if direct client contact is 72. Answer: (C) Primary source Rationale: Judgment sampling involves
nurse to accept the call. However, is not one of anticipated. Goggles are not necessary unless Rationale: This refers to a primary source including samples according to the knowledge
the options. To maintain privacy and safety, the nurse anticipates the splashes of blood, which is a direct account of the investigation of the investigator about the participants in
the nurse covers the client and places the call body fluids, secretions, or excretions may done by the investigator. In contrast to this is a the study.
light within the client’s reach. Additionally, the occur. Shoe protectors are not necessary. secondary source, which is written by 80. Answer: (B) Madeleine Leininger
client’s door should be closed or the room 65. Answer: (C) Quad cane someone other than the original researcher. Rationale: Madeleine Leininger developed the
curtains pulled around the bathing area. Rationale: Crutches and a walker can be 73. Answer: (A) Non-maleficence theory on transcultural theory based on her
60. Answer: (C) Use a sterile plastic container for difficult to maneuver for a client with Rationale: Non-maleficence means do not observations on the behavior of selected
obtaining the specimen. weakness on one side. A cane is better suited cause harm or do any action that will cause people within a culture.
Rationale: Sputum specimens for culture and for client with weakness of the arm and leg on any harm to the patient/client. To do good is 81. Answer: (A) Random
sensitivity testing need to be obtained using one side. However, the quad cane would referred as beneficence. Rationale: Random sampling gives equal
sterile techniques because the test is done to provide the most stability because of the 74. Answer: (C) Res ipsa loquitor chance for all the elements in the population
determine the presence of organisms. If the structure of the cane and because a quad cane Rationale: Res ipsa loquitor literally means the to be picked as part of the sample.
procedure for obtaining the specimen is not has four legs. thing speaks for itself. This means in 82. Answer: (A) Degree of agreement and
sterile, then the specimen is not sterile, then 66. Answer: (D) Left side-lying with the head of operational terms that the injury caused is the disagreement
the specimen would be contaminated and the the bed elevated 45 degrees. proof that there was a negligent act. Rationale: Likert scale is a 5-point summated
results of the test would be invalid. Rationale: To facilitate removal of fluid from 75. Answer: (B) The Board can investigate scale used to determine the degree of
61. Answer: (A) Puts all the four points of the the chest wall, the client is positioned sitting at violations of the nursing law and code of ethics agreement or disagreement of the
walker flat on the floor, puts weight on the the edge of the bed leaning over the bedside Rationale: Quasi-judicial power means that the respondents to a statement in a study
hand pieces, and then walks into it. table with the feet supported on a stool. If the Board of Nursing has the authority to 83. Answer: (B) Sr. Callista Roy
Rationale: When the client uses a walker, the client is unable to sit up, the client is investigate violations of the nursing law and Rationale: Sr. Callista Roy developed the
nurse stands adjacent to the affected side. The positioned lying in bed on the unaffected side can issue summons, subpoena or subpoena Adaptation Model which involves the
client is instructed to put all four points of the with the head of the bed elevated 30 to 45 duces tecum as needed. physiologic mode, self-concept mode, role
walker 2 feet forward flat on the floor before degrees. 76. Answer: (C) May apply for re-issuance of function mode and dependence mode.
putting weight on hand pieces. This will ensure 67. Answer: (D) Reliability his/her license based on certain conditions 84. Answer: (A) Span of control
client safety and prevent stress cracks in the Rationale: Reliability is consistency of the stipulated in RA 9173 Rationale: Span of control refers to the
walker. The client is then instructed to move research instrument. It refers to the Rationale: RA 9173 sec. 24 states that for number of workers who report directly to a
the walker forward and walk into it. repeatability of the instrument in extracting equity and justice, a revoked license maybe re- manager.
62. Answer: (C) Draws one line to cross out the the same responses upon its repeated issued provided that the following conditions 85. Answer: (B) Autonomy
incorrect information and then initials the administration. are met: a) the cause for revocation of license Rationale: Informed consent means that the
change. 68. Answer: (A) Keep the identities of the subject has already been corrected or removed; and, patient fully understands about the surgery,
Rationale: To correct an error documented in a secret b) at least four years has elapsed since the including the risks involved and the alternative
medical record, the nurse draws one line Rationale: Keeping the identities of the license has been revoked. solutions. In giving consent it is done with full
through the incorrect information and then research subject secret will ensure anonymity 77. Answer: (B) Review related literature knowledge and is given freely. The action of
initials the error. An error is never erased and because this will hinder providing link between Rationale: After formulating and delimiting the allowing the patient to decide whether a
correction fluid is never used in the medical the information given to whoever is its source. research problem, the researcher conducts a surgery is to be done or not exemplifies the
record. 69. Answer: (A) Descriptive- correlational review of related literature to determine the bioethical principle of autonomy.
63. Answer: (C) Secures the client safety belts Rationale: Descriptive- correlational study is extent of what has been done on the study by 86. Answer: (C) Avoid wearing canvas shoes.
after transferring to the stretcher. the most appropriate for this study because it previous researchers. Rationale: The client should be instructed to
Rationale: During the transfer of the client studies the variables that could be the 78. Answer: (B) Hawthorne effect avoid wearing canvas shoes. Canvas shoes
after the surgical procedure is complete, the antecedents of the increased incidence of Rationale: Hawthorne effect is based on the cause the feet to perspire, which may, in turn,
nurse should avoid exposure of the client nosocomial infection. study of Elton Mayo and company about the cause skin irritation and breakdown. Both
because of the risk for potential heat loss. 70. Answer: (C) Use of laboratory data effect of an intervention done to improve the cotton and cornstarch absorb perspiration.
Hurried movements and rapid changes in the Rationale: Incidence of nosocomial infection is working conditions of the workers on their The client should be instructed to cut toenails
position should be avoided because these best collected through the use of productivity. It resulted to an increased straight across with nail clippers.
predispose the client to hypotension. At the biophysiologic measures, particularly in vitro productivity but not due to the intervention 87. Answer: (D) Ground beef patties
time of the transfer from the surgery table to but due to the psychological effects of being
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Rationale: Meat is an excellent source of Rationale: Elastic stockings are used to irritation. The nurse should apply the face
complete protein, which this client needs to promote venous return. The nurse needs to mask from the client's nose down to the chin
repair the tissue breakdown caused by remove them once per day to observe the — not vice versa. The nurse should check the
pressure ulcers. Oranges and broccoli supply condition of the skin underneath the stockings. connectors between the oxygen equipment
vitamin C but not protein. Ice cream supplies Applying the stockings increases blood flow to and humidifier to ensure that they're airtight;
only some incomplete protein, making it less the heart. When the stockings are in place, the loosened connectors can cause loss of oxygen.
helpful in tissue repair. leg muscles can still stretch and relax, and the 97. Answer: (B) 4 hours
88. Answer: (D) Sims’ left lateral veins can fill with blood. Rationale: A unit of packed RBCs may be given
Rationale: The Sims' left lateral position is the 93. Answer :(A) Instructing the client to report any over a period of between 1 and 4 hours. It
most common position used to administer a itching, swelling, or dyspnea. shouldn't infuse for longer than 4 hours
cleansing enema because it allows gravity to Rationale: Because administration of blood or because the risk of contamination and sepsis
aid the flow of fluid along the curve of the blood products may cause serious adverse increases after that time. Discard or return to
sigmoid colon. If the client can't assume this effects such as allergic reactions, the nurse the blood bank any blood not given within this
position nor has poor sphincter control, the must monitor the client for these effects. Signs time, according to facility policy.
dorsal recumbent or right lateral position may and symptoms of life-threatening allergic 98. Answer: (B) Immediately before administering
be used. The supine and prone positions are reactions include itching, swelling, and the next dose.
inappropriate and uncomfortable for the dyspnea. Although the nurse should inform Rationale: Measuring the blood drug
client. the client of the duration of the transfusion concentration helps determine whether the
89. Answer: (A) Arrange for typing and cross and should document its administration, these dosing has achieved the therapeutic goal. For
matching of the client’s blood. actions are less critical to the client's measurement of the trough, or lowest, blood
Rationale: The nurse first arranges for typing immediate health. The nurse should assess level of a drug, the nurse draws a blood
and cross matching of the client's blood to vital signs at least hourly during the sample immediately before administering the
ensure compatibility with donor blood. The transfusion. next dose. Depending on the drug's duration
other options, although appropriate when 94. Answer: (B) Decrease the rate of feedings and of action and half-life, peak blood drug levels
preparing to administer a blood transfusion, the concentration of the formula. typically are drawn after administering the
come later. Rationale: Complaints of abdominal next dose.
90. Answer: (A) Independent discomfort and nausea are common in clients 99. Answer: (A) The nurse can implement
Rationale: Nursing interventions are classified receiving tube feedings. Decreasing the rate of medication orders quickly.
as independent, interdependent, or the feeding and the concentration of the Rationale: A floor stock system enables the
dependent. Altering the drug schedule to formula should decrease the client's nurse to implement medication orders quickly.
coincide with the client's daily routine discomfort. Feedings are normally given at It doesn't allow for pharmacist input, nor does
represents an independent intervention, room temperature to minimize abdominal it minimize transcription errors or reinforce
whereas consulting with the physician and cramping. To prevent aspiration during accurate calculations.
pharmacist to change a client's medication feeding, the head of the client's bed should be 100. Answer: (C) Shifting dullness over the
because of adverse reactions represents an elevated at least 30 degrees. Also, to prevent abdomen.
interdependent intervention. Administering an bacterial growth, feeding containers should be Rationale: Shifting dullness over the abdomen
already-prescribed drug on time is a routinely changed every 8 to 12 hours. indicates ascites, an abnormal finding. The
dependent intervention. An intradependent 95. Answer: (D) Roll the vial gently between the other options are normal abdominal findings.
nursing intervention doesn't exist. palms.
91. Answer: (D) Evaluation Rationale: Rolling the vial gently between the
Rationale: The nursing actions described palms produces heat, which helps dissolve the
constitute evaluation of the expected medication. Doing nothing or inverting the vial
outcomes. The findings show that the wouldn't help dissolve the medication. Shaking
expected outcomes have been achieved. the vial vigorously could cause the medication
Assessment consists of the client's history, to break down, altering its action.
physical examination, and laboratory studies. 96. Answer: (B) Assist the client to the semi-
Analysis consists of considering assessment Fowler position if possible.
information to derive the appropriate nursing Rationale: By assisting the client to the semi-
diagnosis. Implementation is the phase of the Fowler position, the nurse promotes easier
nursing process where the nurse puts the plan chest expansion, breathing, and oxygen intake.
of care into action. The nurse should secure the elastic band so
92. Answer: (B) To observe the lower extremities that the face mask fits comfortably and snugly
rather than tightly, which could lead to
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TEST II - Community Health Nursing and Care of a. Excessive fetal activity. a. First low transverse cesarean was for infant looks for it. The nurse is aware that
the Mother and Child b. Larger than normal uterus for active herpes type 2 infections; vaginal estimated age of the infant would be:
gestational age. culture at 39 weeks pregnancy was a. 6 months
1. May arrives at the health care clinic and tells the c. Vaginal bleeding positive. b. 4 months
nurse that her last menstrual period was 9 d. Elevated levels of human chorionic b. First and second caesareans were for c. 8 months
weeks ago. She also tells the nurse that a home gonadotropin. cephalopelvic disproportion. d. 10 months
pregnancy test was positive but she began to c. First caesarean through a classic incision
have mild cramps and is now having moderate 6. A pregnant client is receiving magnesium sulfate as a result of severe fetal distress. 16. Which of the following is the most prominent
vaginal bleeding. During the physical for severe pregnancy induced hypertension d. First low transverse caesarean was for feature of public health nursing?
examination of the client, the nurse notes that (PIH). The clinical findings that would warrant breech position. Fetus in this pregnancy a. It involves providing home care to sick
May has a dilated cervix. The nurse determines use of the antidote , calcium gluconate is: is in a vertex presentation. people who are not confined in the
that May is experiencing which type of abortion? a. Urinary output 90 cc in 2 hours. hospital.
a. Inevitable b. Absent patellar reflexes. 11. Nurse Ryan is aware that the best initial b. Services are provided free of charge to
b. Incomplete c. Rapid respiratory rate above 40/min. approach when trying to take a crying toddler’s people within the catchments area.
c. Threatened d. Rapid rise in blood pressure. temperature is: c. The public health nurse functions as part
d. Septic a. Talk to the mother first and then to the of a team providing a public health
7. During vaginal examination of Janah who is in toddler. nursing services.
2. Nurse Reese is reviewing the record of a labor, the presenting part is at station plus two. b. Bring extra help so it can be done d. Public health nursing focuses on
pregnant client for her first prenatal visit. Which Nurse, correctly interprets it as: quickly. preventive, not curative, services.
of the following data, if noted on the client’s a. Presenting part is 2 cm above the plane c. Encourage the mother to hold the child.
record, would alert the nurse that the client is at of the ischial spines. d. Ignore the crying and screaming. 17. When the nurse determines whether resources
risk for a spontaneous abortion? b. Biparietal diameter is at the level of the were maximized in implementing Ligtas Tigdas,
a. Age 36 years ischial spines. 12. Baby Tina a 3 month old infant just had a cleft lip she is evaluating
b. History of syphilis c. Presenting part in 2 cm below the plane and palate repair. What should the nurse do to a. Effectiveness
c. History of genital herpes of the ischial spines. prevent trauma to operative site? b. Efficiency
d. History of diabetes mellitus d. Biparietal diameter is 2 cm above the a. Avoid touching the suture line, even c. Adequacy
ischial spines. when cleaning. d. Appropriateness
3. Nurse Hazel is preparing to care for a client who b. Place the baby in prone position.
is newly admitted to the hospital with a possible 8. A pregnant client is receiving oxytocin (Pitocin) c. Give the baby a pacifier. 18. Vangie is a new B.S.N. graduate. She wants to
diagnosis of ectopic pregnancy. Nurse Hazel for induction of labor. A condition that warrant d. Place the infant’s arms in soft elbow become a Public Health Nurse. Where should
develops a plan of care for the client and the nurse in-charge to discontinue I.V. infusion restraints. she apply?
determines that which of the following nursing of Pitocin is: a. Department of Health
actions is the priority? a. Contractions every 1 ½ minutes lasting 13. Which action should nurse Marian include in the b. Provincial Health Office
a. Monitoring weight 70-80 seconds. care plan for a 2 month old with heart failure? c. Regional Health Office
b. Assessing for edema b. Maternal temperature 101.2 a. Feed the infant when he cries. d. Rural Health Unit
c. Monitoring apical pulse c. Early decelerations in the fetal heart b. Allow the infant to rest before feeding.
d. Monitoring temperature rate. c. Bathe the infant and administer 19. Tony is aware the Chairman of the Municipal
d. Fetal heart rate baseline 140-160 bpm. medications before feeding. Health Board is:
4. Nurse Oliver is teaching a diabetic pregnant d. Weigh and bathe the infant before a. Mayor
client about nutrition and insulin needs during 9. Calcium gluconate is being administered to a feeding. b. Municipal Health Officer
pregnancy. The nurse determines that the client client with pregnancy induced hypertension c. Public Health Nurse
understands dietary and insulin needs if the (PIH). A nursing action that must be initiated as 14. Nurse Hazel is teaching a mother who plans to d. Any qualified physician
client states that the second half of pregnancy the plan of care throughout injection of the drug discontinue breast feeding after 5 months. The
requires: is: nurse should advise her to include which foods 20. Myra is the public health nurse in a municipality
a. Decreased caloric intake a. Ventilator assistance in her infant’s diet? with a total population of about 20,000. There
b. Increased caloric intake b. CVP readings a. Skim milk and baby food. are 3 rural health midwives among the RHU
c. Decreased Insulin c. EKG tracings b. Whole milk and baby food. personnel. How many more midwife items will
d. Increase Insulin d. Continuous CPR c. Iron-rich formula only. the RHU need?
d. Iron-rich formula and baby food. a. 1
5. Nurse Michelle is assessing a 24 year old client 10. A trial for vaginal delivery after an earlier b. 2
with a diagnosis of hydatidiform mole. She is caesarean, would likely to be given to a gravida, 15. Mommy Linda is playing with her infant, who is c. 3
aware that one of the following is unassociated who had: sitting securely alone on the floor of the clinic. d. The RHU does not need any more
with this condition? The mother hides a toy behind her back and the midwife item.
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26. The nurse is caring for a primigravid client in the 32. Jannah is admitted to the labor and delivery b. Dehydration and diarrhea
21. According to Freeman and Heinrich, community labor and delivery area. Which condition would unit. The critical laboratory result for this client c. Bradycardia and hypotension
health nursing is a developmental service. Which place the client at risk for disseminated would be: d. Petechiae and hematuria
of the following best illustrates this statement? intravascular coagulation (DIC)? a. Oxygen saturation
a. The community health nurse a. Intrauterine fetal death. b. Iron binding capacity 38. To evaluate a woman’s understanding about the
continuously develops himself b. Placenta accreta. c. Blood typing use of diaphragm for family planning, Nurse
personally and professionally. c. Dysfunctional labor. d. Serum Calcium Trish asks her to explain how she will use the
b. Health education and community d. Premature rupture of the membranes. appliance. Which response indicates a need for
organizing are necessary in providing 33. Nurse Gina is aware that the most common further health teaching?
community health services. 27. A fullterm client is in labor. Nurse Betty is aware condition found during the second-trimester of a. “I should check the diaphragm carefully
c. Community health nursing is intended that the fetal heart rate would be: pregnancy is: for holes every time I use it”
primarily for health promotion and a. 80 to 100 beats/minute a. Metabolic alkalosis b. “I may need a different size of
prevention and treatment of disease. b. 100 to 120 beats/minute b. Respiratory acidosis diaphragm if I gain or lose weight more
d. The goal of community health nursing is c. 120 to 160 beats/minute c. Mastitis than 20 pounds”
to provide nursing services to people in d. 160 to 180 beats/minute d. Physiologic anemia c. “The diaphragm must be left in place for
their own places of residence. atleast 6 hours after intercourse”
28. The skin in the diaper area of a 7 month old 34. Nurse Lynette is working in the triage area of an d. “I really need to use the diaphragm and
22. Nurse Tina is aware that the disease declared infant is excoriated and red. Nurse Hazel should emergency department. She sees that several jelly most during the middle of my
through Presidential Proclamation No. 4 as a instruct the mother to: pediatric clients arrive simultaneously. The client menstrual cycle”.
target for eradication in the Philippines is? a. Change the diaper more often. who needs to be treated first is:
a. Poliomyelitis b. Apply talc powder with diaper changes. a. A crying 5 year old child with a 39. Hypoxia is a common complication of
b. Measles c. Wash the area vigorously with each laceration on his scalp. laryngotracheobronchitis. Nurse Oliver should
c. Rabies diaper change. b. A 4 year old child with a barking coughs frequently assess a child with
d. Neonatal tetanus d. Decrease the infant’s fluid intake to and flushed appearance. laryngotracheobronchitis for:
decrease saturating diapers. c. A 3 year old child with Down syndrome a. Drooling
23. May knows that the step in community who is pale and asleep in his mother’s b. Muffled voice
organizing that involves training of potential 29. Nurse Carla knows that the common cardiac arms. c. Restlessness
leaders in the community is: anomalies in children with Down Syndrome (tri- d. A 2 year old infant with stridorous d. Low-grade fever
a. Integration somy 21) is: breath sounds, sitting up in his mother’s
b. Community organization a. Atrial septal defect arms and drooling. 40. How should Nurse Michelle guide a child who is
c. Community study b. Pulmonic stenosis blind to walk to the playroom?
d. Core group formation c. Ventricular septal defect 35. Maureen in her third trimester arrives at the a. Without touching the child, talk
d. Endocardial cushion defect emergency room with painless vaginal bleeding. continuously as the child walks down the
24. Beth a public health nurse takes an active role in Which of the following conditions is suspected? hall.
community participation. What is the primary 30. Malou was diagnosed with severe preeclampsia a. Placenta previa b. Walk one step ahead, with the child’s
goal of community organizing? is now receiving I.V. magnesium sulfate. The b. Abruptio placentae hand on the nurse’s elbow.
a. To educate the people regarding adverse effects associated with magnesium c. Premature labor c. Walk slightly behind, gently guiding the
community health problems sulfate is: d. Sexually transmitted disease child forward.
b. To mobilize the people to resolve a. Anemia d. Walk next to the child, holding the
community health problems b. Decreased urine output 36. A young child named Richard is suspected of child’s hand.
c. To maximize the community’s resources c. Hyperreflexia having pinworms. The community nurse collects
in dealing with health problems. d. Increased respiratory rate a stool specimen to confirm the diagnosis. The 41. When assessing a newborn diagnosed with
d. To maximize the community’s resources nurse should schedule the collection of this ductus arteriosus, Nurse Olivia should expect
in dealing with health problems. 31. A 23 year old client is having her menstrual specimen for: that the child most likely would have an:
period every 2 weeks that last for 1 week. This a. Just before bedtime a. Loud, machinery-like murmur.
25. Tertiary prevention is needed in which stage of type of menstrual pattern is bets defined by: b. After the child has been bathe b. Bluish color to the lips.
the natural history of disease? a. Menorrhagia c. Any time during the day c. Decreased BP reading in the upper
a. Pre-pathogenesis b. Metrorrhagia d. Early in the morning extremities
b. Pathogenesis c. Dyspareunia d. Increased BP reading in the upper
c. Prodromal d. Amenorrhea 37. In doing a child’s admission assessment, Nurse extremities.
d. Terminal Betty should be alert to note which signs or
symptoms of chronic lead poisoning? 42. The reason nurse May keeps the neonate in a
a. Irritability and seizures neutral thermal environment is that when a
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newborn becomes too cool, the neonate 47. Barangay Pinoy had an outbreak of German c. Steptococcus pneumoniae d. Use of protective footwear, such as
requires: measles. To prevent congenital rubella, what is d. Neisseria meningitidis rubber boots
a. Less oxygen, and the newborn’s the BEST advice that you can give to women in
metabolic rate increases. the first trimester of pregnancy in the barangay 52. The student nurse is aware that the 58. Several clients is newly admitted and diagnosed
b. More oxygen, and the newborn’s Pinoy? pathognomonic sign of measles is Koplik’s spot with leprosy. Which of the following clients
metabolic rate decreases. a. Advise them on the signs of German and you may see Koplik’s spot by inspecting the: should be classified as a case of multibacillary
c. More oxygen, and the newborn’s measles. a. Nasal mucosa leprosy?
metabolic rate increases. b. Avoid crowded places, such as markets b. Buccal mucosa a. 3 skin lesions, negative slit skin smear
d. Less oxygen, and the newborn’s and movie houses. c. Skin on the abdomen b. 3 skin lesions, positive slit skin smear
metabolic rate decreases. c. Consult at the health center where d. Skin on neck c. 5 skin lesions, negative slit skin smear
rubella vaccine may be given. d. 5 skin lesions, positive slit skin smear
43. Before adding potassium to an infant’s I.V. line, d. Consult a physician who may give them 53. Angel was diagnosed as having Dengue fever.
Nurse Ron must be sure to assess whether this rubella immunoglobulin. You will say that there is slow capillary refill 59. Nurses are aware that diagnosis of leprosy is
infant has: when the color of the nailbed that you pressed highly dependent on recognition of symptoms.
a. Stable blood pressure 48. Myrna a public health nurse knows that to does not return within how many seconds? Which of the following is an early sign of
b. Patant fontanelles determine possible sources of sexually a. 3 seconds leprosy?
c. Moro’s reflex transmitted infections, the BEST method that b. 6 seconds a. Macular lesions
d. Voided may be undertaken is: c. 9 seconds b. Inability to close eyelids
a. Contact tracing d. 10 seconds c. Thickened painful nerves
44. Nurse Carla should know that the most common b. Community survey d. Sinking of the nosebridge
causative factor of dermatitis in infants and c. Mass screening tests 54. In Integrated Management of Childhood Illness,
younger children is: d. Interview of suspects the nurse is aware that the severe conditions 60. Marie brought her 10 month old infant for
a. Baby oil generally require urgent referral to a hospital. consultation because of fever, started 4 days
b. Baby lotion 49. A 33-year old female client came for Which of the following severe conditions DOES prior to consultation. In determining malaria
c. Laundry detergent consultation at the health center with the chief NOT always require urgent referral to a hospital? risk, what will you do?
d. Powder with cornstarch complaint of fever for a week. Accompanying a. Mastoiditis a. Perform a tourniquet test.
symptoms were muscle pains and body malaise. b. Severe dehydration b. Ask where the family resides.
45. During tube feeding, how far above an infant’s A week after the start of fever, the client noted c. Severe pneumonia c. Get a specimen for blood smear.
stomach should the nurse hold the syringe with yellowish discoloration of his sclera. History d. Severe febrile disease d. Ask if the fever is present every day.
formula? showed that he waded in flood waters about 2
a. 6 inches weeks before the onset of symptoms. Based on 55. Myrna a public health nurse will conduct 61. Susie brought her 4 years old daughter to the
b. 12 inches her history, which disease condition will you outreach immunization in a barangay Masay RHU because of cough and colds. Following the
c. 18 inches suspect? with a population of about 1500. The estimated IMCI assessment guide, which of the following is
d. 24 inches a. Hepatitis A number of infants in the barangay would be: a danger sign that indicates the need for urgent
b. Hepatitis B a. 45 infants referral to a hospital?
46. In a mothers’ class, Nurse Lhynnete discussed c. Tetanus b. 50 infants a. Inability to drink
childhood diseases such as chicken pox. Which d. Leptospirosis c. 55 infants b. High grade fever
of the following statements about chicken pox is d. 65 infants c. Signs of severe dehydration
correct? 50. Mickey a 3-year old client was brought to the d. Cough for more than 30 days
a. The older one gets, the more susceptible health center with the chief complaint of severe 56. The community nurse is aware that the
he becomes to the complications of diarrhea and the passage of “rice water” stools. biological used in Expanded Program on 62. Jimmy a 2-year old child revealed “baggy pants”.
chicken pox. The client is most probably suffering from which Immunization (EPI) should NOT be stored in the As a nurse, using the IMCI guidelines, how will
b. A single attack of chicken pox will condition? freezer? you manage Jimmy?
prevent future episodes, including a. Giardiasis a. DPT a. Refer the child urgently to a hospital for
conditions such as shingles. b. Cholera b. Oral polio vaccine confinement.
c. To prevent an outbreak in the c. Amebiasis c. Measles vaccine b. Coordinate with the social worker to
community, quarantine may be imposed d. Dysentery d. MMR enroll the child in a feeding program.
by health authorities. c. Make a teaching plan for the mother,
d. Chicken pox vaccine is best given when 51. The most prevalent form of meningitis among 57. It is the most effective way of controlling focusing on menu planning for her child.
there is an impending outbreak in the children aged 2 months to 3 years is caused by schistosomiasis in an endemic area? d. Assess and treat the child for health
community. which microorganism? a. Use of molluscicides problems like infections and intestinal
a. Hemophilus influenzae b. Building of foot bridges parasitism.
b. Morbillivirus c. Proper use of sanitary toilets
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63. Gina is using Oresol in the management of 68. The nurse explains to a breastfeeding mother 74. After reviewing the Myrna’s maternal history of b. The parent’s expression of interest
diarrhea of her 3-year old child. She asked you that breast milk is sufficient for all of the baby’s magnesium sulfate during labor, which condition about the size of the new born.
what to do if her child vomits. As a nurse you will nutrient needs only up to: would nurse Richard anticipate as a potential c. The parents’ indication that they want to
tell her to: a. 5 months problem in the neonate? see the newborn.
a. Bring the child to the nearest hospital b. 6 months a. Hypoglycemia d. The parents’ interactions with each
for further assessment. c. 1 year b. Jitteriness other.
b. Bring the child to the health center for d. 2 years c. Respiratory depression
intravenous fluid therapy. d. Tachycardia 80. Following a precipitous delivery, examination of
c. Bring the child to the health center for 69. Nurse Ron is aware that the gestational age of a the client's vagina reveals a fourth-degree
assessment by the physician. conceptus that is considered viable (able to live 75. Which symptom would indicate the Baby laceration. Which of the following would be
d. Let the child rest for 10 minutes then outside the womb) is: Alexandra was adapting appropriately to extra- contraindicated when caring for this client?
continue giving Oresol more slowly. a. 8 weeks uterine life without difficulty? a. Applying cold to limit edema during the
b. 12 weeks a. Nasal flaring first 12 to 24 hours.
64. Nikki a 5-month old infant was brought by his c. 24 weeks b. Light audible grunting b. Instructing the client to use two or more
mother to the health center because of diarrhea d. 32 weeks c. Respiratory rate 40 to 60 peripads to cushion the area.
for 4 to 5 times a day. Her skin goes back slowly breaths/minute c. Instructing the client on the use of sitz
after a skin pinch and her eyes are sunken. Using 70. When teaching parents of a neonate the proper d. Respiratory rate 60 to 80 baths if ordered.
the IMCI guidelines, you will classify this infant in position for the neonate’s sleep, the nurse breaths/minute d. Instructing the client about the
which category? Patricia stresses the importance of placing the importance of perineal (kegel) exercises.
a. No signs of dehydration neonate on his back to reduce the risk of which 76. When teaching umbilical cord care for Jennifer a
b. Some dehydration of the following? new mother, the nurse Jenny would include 81. A pregnant woman accompanied by her
c. Severe dehydration a. Aspiration which information? husband, seeks admission to the labor and
d. The data is insufficient. b. Sudden infant death syndrome (SIDS) a. Apply peroxide to the cord with each delivery area. She states that she's in labor and
c. Suffocation diaper change says she attended the facility clinic for prenatal
65. Chris a 4-month old infant was brought by her d. Gastroesophageal reflux (GER) b. Cover the cord with petroleum jelly after care. Which question should the nurse Oliver ask
mother to the health center because of cough. bathing her first?
His respiratory rate is 42/minute. Using the 71. Which finding might be seen in baby James a c. Keep the cord dry and open to air a. “Do you have any chronic illnesses?”
Integrated Management of Child Illness (IMCI) neonate suspected of having an infection? d. Wash the cord with soap and water each b. “Do you have any allergies?”
guidelines of assessment, his breathing is a. Flushed cheeks day during a tub bath. c. “What is your expected due date?”
considered as: b. Increased temperature d. “Who will be with you during labor?”
a. Fast c. Decreased temperature 77. Nurse John is performing an assessment on a
b. Slow d. Increased activity level neonate. Which of the following findings is 82. A neonate begins to gag and turns a dusky color.
c. Normal considered common in the healthy neonate? What should the nurse do first?
d. Insignificant 72. Baby Jenny who is small-for-gestation is at a. Simian crease a. Calm the neonate.
increased risk during the transitional period for b. Conjunctival hemorrhage b. Notify the physician.
66. Maylene had just received her 4th dose of which complication? c. Cystic hygroma c. Provide oxygen via face mask as ordered
tetanus toxoid. She is aware that her baby will a. Anemia probably due to chronic fetal d. Bulging fontanelle d. Aspirate the neonate’s nose and mouth
have protection against tetanus for hyposia with a bulb syringe.
a. 1 year b. Hyperthermia due to decreased 78. Dr. Esteves decides to artificially rupture the
b. 3 years glycogen stores membranes of a mother who is on labor. 83. When a client states that her "water broke,"
c. 5 years c. Hyperglycemia due to decreased Following this procedure, the nurse Hazel checks which of the following actions would be
d. Lifetime glycogen stores the fetal heart tones for which the following inappropriate for the nurse to do?
d. Polycythemia probably due to chronic reasons? a. Observing the pooling of straw-colored
67. Nurse Ron is aware that unused BCG should be fetal hypoxia a. To determine fetal well-being. fluid.
discarded after how many hours of b. To assess for prolapsed cord b. Checking vaginal discharge with nitrazine
reconstitution? 73. Marjorie has just given birth at 42 weeks’ c. To assess fetal position paper.
a. 2 hours gestation. When the nurse assessing the d. To prepare for an imminent delivery. c. Conducting a bedside ultrasound for an
b. 4 hours neonate, which physical finding is expected? 79. Which of the following would be least likely to amniotic fluid index.
c. 8 hours a. A sleepy, lethargic baby indicate anticipated bonding behaviors by new d. Observing for flakes of vernix in the
d. At the end of the day b. Lanugo covering the body parents? vaginal discharge.
c. Desquamation of the epidermis a. The parents’ willingness to touch and
d. Vernix caseosa covering the body hold the new born. 84. A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is
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successfully resuscitated. Within several hours c. Decreased inspiratory capacity flank pain, and costovertebral angle tenderness. a. Uterine inversion
she develops respiratory grunting, cyanosis, d. Decreased oxygen consumption Which of the following diagnoses is most likely? b. Uterine atony
tachypnea, nasal flaring, and retractions. She's a. Asymptomatic bacteriuria c. Uterine involution
diagnosed with respiratory distress syndrome, 90. Emily has gestational diabetes and it is usually b. Bacterial vaginosis d. Uterine discomfort
intubated, and placed on a ventilator. Which managed by which of the following therapy? c. Pyelonephritis
nursing action should be included in the baby's a. Diet d. Urinary tract infection (UTI)
plan of care to prevent retinopathy of b. Long-acting insulin
prematurity? c. Oral hypoglycemic 96. Rh isoimmunization in a pregnant client
a. Cover his eyes while receiving oxygen. d. Oral hypoglycemic drug and insulin develops during which of the following
b. Keep her body temperature low. conditions?
c. Monitor partial pressure of oxygen 91. Magnesium sulfate is given to Jemma with a. Rh-positive maternal blood crosses into
(Pao2) levels. preeclampsia to prevent which of the following fetal blood, stimulating fetal antibodies.
d. Humidify the oxygen. condition? b. Rh-positive fetal blood crosses into
a. Hemorrhage maternal blood, stimulating maternal
85. Which of the following is normal newborn b. Hypertension antibodies.
calorie intake? c. Hypomagnesemia c. Rh-negative fetal blood crosses into
a. 110 to 130 calories per kg. d. Seizure maternal blood, stimulating maternal
b. 30 to 40 calories per lb of body weight. antibodies.
c. At least 2 ml per feeding 92. Cammile with sickle cell anemia has an increased d. Rh-negative maternal blood crosses into
d. 90 to 100 calories per kg risk for having a sickle cell crisis during fetal blood, stimulating fetal antibodies.
pregnancy. Aggressive management of a sickle
86. Nurse John is knowledgeable that usually cell crisis includes which of the following 97. To promote comfort during labor, the nurse John
individual twins will grow appropriately and at measures? advises a client to assume certain positions and
the same rate as singletons until how many a. Antihypertensive agents avoid others. Which position may cause
weeks? b. Diuretic agents maternal hypotension and fetal hypoxia?
a. 16 to 18 weeks c. I.V. fluids a. Lateral position
b. 18 to 22 weeks d. Acetaminophen (Tylenol) for pain b. Squatting position
c. 30 to 32 weeks c. Supine position
d. 38 to 40 weeks 93. Which of the following drugs is the antidote for d. Standing position
magnesium toxicity?
87. Which of the following classifications applies to a. Calcium gluconate (Kalcinate) 98. Celeste who used heroin during her pregnancy
monozygotic twins for whom the cleavage of the b. Hydralazine (Apresoline) delivers a neonate. When assessing the neonate,
fertilized ovum occurs more than 13 days after c. Naloxone (Narcan) the nurse Lhynnette expects to find:
fertilization? d. Rho (D) immune globulin (RhoGAM) a. Lethargy 2 days after birth.
a. conjoined twins b. Irritability and poor sucking.
b. diamniotic dichorionic twins 94. Marlyn is screened for tuberculosis during her c. A flattened nose, small eyes, and thin
c. diamniotic monochorionic twin first prenatal visit. An intradermal injection of lips.
d. monoamniotic monochorionic twins purified protein derivative (PPD) of the d. Congenital defects such as limb
tuberculin bacilli is given. She is considered to anomalies.
88. Tyra experienced painless vaginal bleeding has have a positive test for which of the following
just been diagnosed as having a placenta previa. results? 99. The uterus returns to the pelvic cavity in which
Which of the following procedures is usually a. An indurated wheal under 10 mm in of the following time frames?
performed to diagnose placenta previa? diameter appears in 6 to 12 hours. a. 7th to 9th day postpartum.
a. Amniocentesis b. An indurated wheal over 10 mm in b. 2 weeks postpartum.
b. Digital or speculum examination diameter appears in 48 to 72 hours. c. End of 6th week postpartum.
c. External fetal monitoring c. A flat circumcised area under 10 mm in d. When the lochia changes to alba.
d. Ultrasound diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in 100. Maureen, a primigravida client, age 20, has
89. Nurse Arnold knows that the following changes diameter appears in 48 to 72 hours. just completed a difficult, forceps-assisted
in respiratory functioning during pregnancy is delivery of twins. Her labor was unusually
considered normal: 95. Dianne, 24 year-old is 27 weeks’ pregnant long and required oxytocin (Pitocin)
a. Increased tidal volume arrives at her physician’s office with complaints augmentation. The nurse who's caring for her
b. Increased expiratory volume of fever, nausea, vomiting, malaise, unilateral should stay alert for:
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Answers and Rationale – Community Health result in injury to the mother and the fetus if 8 months, infants can sit securely alone but embolism may trigger normal clotting
Nursing and Care of the Mother and Child Pitocin is not discontinued. cannot understand the permanence of objects. mechanisms; if clotting factors are depleted,
9. Answer: (C) EKG tracings 16. Answer: (D) Public health nursing focuses on DIC may occur. Placenta accreta, dysfunctional
1. Answer: (A) Inevitable Rationale: A potential side effect of calcium preventive, not curative, services. labor, and premature rupture of the
Rationale: An inevitable abortion is termination gluconate administration is cardiac arrest. Rationale: The catchments area in PHN consists membranes aren't associated with DIC.
of pregnancy that cannot be prevented. Continuous monitoring of cardiac activity (EKG) of a residential community, many of whom are 27. Answer: (C) 120 to 160 beats/minute
Moderate to severe bleeding with mild throught administration of calcium gluconate is well individuals who have greater need for Rationale: A rate of 120 to 160 beats/minute in
cramping and cervical dilation would be noted an essential part of care. preventive rather than curative services. the fetal heart appropriate for filling the heart
in this type of abortion. 10. Answer: (D) First low transverse caesarean was 17. Answer: (B) Efficiency with blood and pumping it out to the system.
2. Answer: (B) History of syphilis for breech position. Fetus in this pregnancy is in Rationale: Efficiency is determining whether the 28. Answer: (A) Change the diaper more often.
Rationale: Maternal infections such as syphilis, a vertex presentation. goals were attained at the least possible cost. Rationale: Decreasing the amount of time the
toxoplasmosis, and rubella are causes of Rationale: This type of client has no obstetrical 18. Answer: (D) Rural Health Unit skin comes contact with wet soiled diapers will
spontaneous abortion. indication for a caesarean section as she did Rationale: R.A. 7160 devolved basic health help heal the irritation.
3. Answer: (C) Monitoring apical pulse with her first caesarean delivery. services to local government units (LGU’s ). The 29. Answer: (D) Endocardial cushion defect
Rationale: Nursing care for the client with a 11. Answer: (A) Talk to the mother first and then to public health nurse is an employee of the LGU. Rationale: Endocardial cushion defects are seen
possible ectopic pregnancy is focused on the toddler. 19. Answer: (A) Mayor most in children with Down syndrome,
preventing or identifying hypovolemic shock Rationale: When dealing with a crying toddler, Rationale: The local executive serves as the asplenia, or polysplenia.
and controlling pain. An elevated pulse rate is the best approach is to talk to the mother and chairman of the Municipal Health Board. 30. Answer: (B) Decreased urine output
an indicator of shock. ignore the toddler first. This approach helps the 20. Answer: (A) 1 Rationale: Decreased urine output may occur in
4. Answer: (B) Increased caloric intake toddler get used to the nurse before she Rationale: Each rural health midwife is given a clients receiving I.V. magnesium and should be
Rationale: Glucose crosses the placenta, but attempts any procedures. It also gives the population assignment of about 5,000. monitored closely to keep urine output at
insulin does not. High fetal demands for toddler an opportunity to see that the mother 21. Answer: (B) Health education and community greater than 30 ml/hour, because magnesium is
glucose, combined with the insulin resistance trusts the nurse. organizing are necessary in providing excreted through the kidneys and can easily
caused by hormonal changes in the last half of 12. Answer: (D) Place the infant’s arms in soft community health services. Rationale: The accumulate to toxic levels.
pregnancy can result in elevation of maternal elbow restraints. community health nurse develops the health 31. Answer: (A) Menorrhagia
blood glucose levels. This increases the Rationale: Soft restraints from the upper arm to capability of people through health education Rationale: Menorrhagia is an excessive
mother’s demand for insulin and is referred to the wrist prevent the infant from touching her and community organizing activities. menstrual period.
as the diabetogenic effect of pregnancy. lip but allow him to hold a favorite item such as 22. Answer: (B) Measles 32. Answer: (C) Blood typing
5. Answer: (A) Excessive fetal activity. a blanket. Because they could damage the Rationale: Presidential Proclamation No. 4 is on Rationale: Blood type would be a critical value
Rationale: The most common signs and operative site, such as objects as pacifiers, the Ligtas Tigdas Program. to have because the risk of blood loss is always
symptoms of hydatidiform mole includes suction catheters, and small spoons shouldn’t 23. Answer: (D) Core group formation a potential complication during the labor and
elevated levels of human chorionic be placed in a baby’s mouth after cleft repair. A Rationale: In core group formation, the nurse is delivery process. Approximately 40% of a
gonadotropin, vaginal bleeding, larger than baby in a prone position may rub her face on able to transfer the technology of community woman’s cardiac output is delivered to the
normal uterus for gestational age, failure to the sheets and traumatize the operative site. organizing to the potential or informal uterus, therefore, blood loss can occur quite
detect fetal heart activity even with sensitive The suture line should be cleaned gently to community leaders through a training program. rapidly in the event of uncontrolled bleeding.
instruments, excessive nausea and vomiting, prevent infection, which could interfere with 24. Answer: (D) To maximize the community’s 33. Answer: (D) Physiologic anemia
and early development of pregnancy-induced healing and damage the cosmetic appearance resources in dealing with health problems. Rationale: Hemoglobin values and hematocrit
hypertension. Fetal activity would not be noted. of the repair. Rationale: Community organizing is a decrease during pregnancy as the increase in
6. Answer: (B) Absent patellar reflexes 13. Answer: (B) Allow the infant to rest before developmental service, with the goal of plasma volume exceeds the increase in red
Rationale: Absence of patellar reflexes is an feeding. developing the people’s self-reliance in dealing blood cell production.
indicator of hypermagnesemia, which requires Rationale: Because feeding requires so much with community health problems. A, B and C 34. Answer: (D) A 2 year old infant with stridorous
administration of calcium gluconate. energy, an infant with heart failure should rest are objectives of contributory objectives to this breath sounds, sitting up in his mother’s arms
7. Answer: (C) Presenting part in 2 cm below the before feeding. goal. and drooling.
plane of the ischial spines. 14. Answer: (C) Iron-rich formula only. 25. Answer: (D) Terminal Rationale: The infant with the airway
Rationale: Fetus at station plus two indicates Rationale: The infants at age 5 months should Rationale: Tertiary prevention involves emergency should be treated first, because of
that the presenting part is 2 cm below the receive iron-rich formula and that they rehabilitation, prevention of permanent the risk of epiglottitis.
plane of the ischial spines. shouldn’t receive solid food, even baby food disability and disability limitations appropriate 35. Answer: (A) Placenta previa
8. Answer: (A) Contractions every 1 ½ minutes until age 6 months. for convalescents, the disabled, complicated Rationale: Placenta previa with painless vaginal
lasting 70-80 seconds. 15. Answer: (D) 10 months cases and the terminally ill (those in the bleeding.
Rationale: Contractions every 1 ½ minutes Rationale: A 10 month old infant can sit alone terminal stage of a disease). 36. Answer: (D) Early in the morning
lasting 70-80 seconds, is indicative of and understands object permanence, so he 26. Answer: (A) Intrauterine fetal death. Rationale: Based on the nurse’s knowledge of
hyperstimulation of the uterus, which could would look for the hidden toy. At age 4 to 6 Rationale: Intrauterine fetal death, abruptio microbiology, the specimen should be collected
months, infants can’t sit securely alone. At age placentae, septic shock, and amniotic fluid early in the morning. The rationale for this
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timing is that, because the female worm lays Rationale: Eczema or dermatitis is an allergic Rationale: Adequate blood supply to the area not able to feed or drink, vomits everything,
eggs at night around the perineal area, the first skin reaction caused by an offending allergen. allows the return of the color of the nailbed convulsions, abnormally sleepy or difficult to
bowel movement of the day will yield the best The topical allergen that is the most common within 3 seconds. awaken.
results. The specific type of stool specimen causative factor is laundry detergent. 54. Answer: (B) Severe dehydration 62. Answer: (A) Refer the child urgently to a
used in the diagnosis of pinworms is called the 45. Answer: (A) 6 inches Rationale: The order of priority in the hospital for confinement.
tape test. Rationale: This distance allows for easy flow of management of severe dehydration is as Rationale: “Baggy pants” is a sign of severe
37. Answer: (A) Irritability and seizures the formula by gravity, but the flow will be slow follows: intravenous fluid therapy, referral to a marasmus. The best management is urgent
Rationale: Lead poisoning primarily affects the enough not to overload the stomach too facility where IV fluids can be initiated within 30 referral to a hospital.
CNS, causing increased intracranial pressure. rapidly. minutes, Oresol or nasogastric tube. When the 63. Answer: (D) Let the child rest for 10 minutes
This condition results in irritability and changes 46. Answer: (A) The older one gets, the more foregoing measures are not possible or then continue giving Oresol more slowly.
in level of consciousness, as well as seizure susceptible he becomes to the complications of effective, then urgent referral to the hospital is Rationale: If the child vomits persistently, that
disorders, hyperactivity, and learning chicken pox. done. is, he vomits everything that he takes in, he has
disabilities. Rationale: Chicken pox is usually more severe in 55. Answer: (A) 45 infants to be referred urgently to a hospital. Otherwise,
38. Answer: (D) “I really need to use the diaphragm adults than in children. Complications, such as Rationale: To estimate the number of infants, vomiting is managed by letting the child rest for
and jelly most during the middle of my pneumonia, are higher in incidence in adults. multiply total population by 3%. 10 minutes and then continuing with Oresol
menstrual cycle”. 47. Answer: (D) Consult a physician who may give 56. Answer: (A) DPT administration. Teach the mother to give Oresol
Rationale: The woman must understand that, them rubella immunoglobulin. Rationale: DPT is sensitive to freezing. The more slowly.
although the “fertile” period is approximately Rationale: Rubella vaccine is made up of appropriate storage temperature of DPT is 2 to 64. Answer: (B) Some dehydration
mid-cycle, hormonal variations do occur and attenuated German measles viruses. This is 8° C only. OPV and measles vaccine are highly Rationale: Using the assessment guidelines of
can result in early or late ovulation. To be contraindicated in pregnancy. Immune globulin, sensitive to heat and require freezing. MMR is IMCI, a child (2 months to 5 years old) with
effective, the diaphragm should be inserted a specific prophylactic against German measles, not an immunization in the Expanded Program diarrhea is classified as having SOME
before every intercourse. may be given to pregnant women. on Immunization. DEHYDRATION if he shows 2 or more of the
39. Answer: (C) Restlessness 48. Answer: (A) Contact tracing 57. Answer: (C) Proper use of sanitary toilets following signs: restless or irritable, sunken
Rationale: In a child, restlessness is the earliest Rationale: Contact tracing is the most practical Rationale: The ova of the parasite get out of the eyes, the skin goes back slow after a skin pinch.
sign of hypoxia. Late signs of hypoxia in a child and reliable method of finding possible sources human body together with feces. Cutting the 65. Answer: (C) Normal
are associated with a change in color, such as of person-to-person transmitted infections, cycle at this stage is the most effective way of Rationale: In IMCI, a respiratory rate of
pallor or cyanosis. such as sexually transmitted diseases. preventing the spread of the disease to 50/minute or more is fast breathing for an
40. Answer: (B) Walk one step ahead, with the 49. Answer: (D) Leptospirosis susceptible hosts. infant aged 2 to 12 months.
child’s hand on the nurse’s elbow. Rationale: Leptospirosis is transmitted through 58. Answer: (D) 5 skin lesions, positive slit skin 66. Answer: (A) 1 year
Rationale: This procedure is generally contact with the skin or mucous membrane smear Rationale: The baby will have passive natural
recommended to follow in guiding a person with water or moist soil contaminated with Rationale: A multibacillary leprosy case is one immunity by placental transfer of antibodies.
who is blind. urine of infected animals, like rats. who has a positive slit skin smear and at least 5 The mother will have active artificial immunity
41. Answer: (A) Loud, machinery-like murmur. 50. Answer: (B) Cholera skin lesions. lasting for about 10 years. 5 doses will give the
Rationale: A loud, machinery-like murmur is a Rationale: Passage of profuse watery stools is 59. Answer: (C) Thickened painful nerves mother lifetime protection.
characteristic finding associated with patent the major symptom of cholera. Both amebic Rationale: The lesion of leprosy is not macular. 67. Answer: (B) 4 hours
ductus arteriosus. and bacillary dysentery are characterized by the It is characterized by a change in skin color Rationale: While the unused portion of other
42. Answer: (C) More oxygen, and the newborn’s presence of blood and/or mucus in the stools. (either reddish or whitish) and loss of sensation, biologicals in EPI may be given until the end of
metabolic rate increases. Giardiasis is characterized by fat malabsorption sweating and hair growth over the lesion. the day, only BCG is discarded 4 hours after
Rationale: When cold, the infant requires more and, therefore, steatorrhea. Inability to close the eyelids (lagophthalmos) reconstitution. This is why BCG immunization is
oxygen and there is an increase in metabolic 51. Answer: (A) Hemophilus influenzae and sinking of the nosebridge are late scheduled only in the morning.
rate. Non-shievering thermogenesis is a Rationale: Hemophilus meningitis is unusual symptoms. 68. Answer: (B) 6 months
complex process that increases the metabolic over the age of 5 years. In developing countries, 60. Answer: (B) Ask where the family resides. Rationale: After 6 months, the baby’s nutrient
rate and rate of oxygen consumption, the peak incidence is in children less than 6 Rationale: Because malaria is endemic, the first needs, especially the baby’s iron requirement,
therefore, the newborn increase heat months of age. Morbillivirus is the etiology of question to determine malaria risk is where the can no longer be provided by mother’s milk
production. measles. Streptococcus pneumonia and client’s family resides. If the area of residence is alone.
43. Answer: (D) Voided Neisseria meningitidis may cause meningitis, not a known endemic area, ask if the child had 69. Answer: (C) 24 weeks
Rationale: Before administering potassium I.V. but age distribution is not specific in young traveled within the past 6 months, where she Rationale: At approximately 23 to 24 weeks’
to any client, the nurse must first check that the children. was brought and whether she stayed overnight gestation, the lungs are developed enough to
client’s kidneys are functioning and that the 52. Answer: (B) Buccal mucosa in that area. sometimes maintain extrauterine life. The lungs
client is voiding. If the client is not voiding, the Rationale: Koplik’s spot may be seen on the 61. Answer: (A) Inability to drink are the most immature system during the
nurse should withhold the potassium and notify mucosa of the mouth or the throat. Rationale: A sick child aged 2 months to 5 years gestation period. Medical care for premature
the physician. 53. Answer: (A) 3 seconds must be referred urgently to a hospital if labor begins much earlier (aggressively at 21
44. Answer: (c) Laundry detergent he/she has one or more of the following signs: weeks’ gestation)
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70. Answer: (B) Sudden infant death syndrome infection. Peroxide could be painful and isn’t the neonate. If the problem recurs or the day after fertilization results in diamniotic
(SIDS) recommended. neonate's color doesn't improve readily, the dicchorionic twins. Cleavage that occurs
Rationale: Supine positioning is recommended 77. Answer: (B) Conjunctival hemorrhage nurse should notify the physician. between days 3 and 8 results in diamniotic
to reduce the risk of SIDS in infancy. The risk of Rationale: Conjunctival hemorrhages are Administering oxygen when the airway isn't monochorionic twins. Cleavage that occurs
aspiration is slightly increased with the supine commonly seen in neonates secondary to the clear would be ineffective. between days 8 to 13 result in monoamniotic
position. Suffocation would be less likely with cranial pressure applied during the birth 83. Answer: (C) Conducting a bedside ultrasound monochorionic twins.
an infant supine than prone and the position process. Bulging fontanelles are a sign of for an amniotic fluid index. 88. Answer: (D) Ultrasound
for GER requires the head of the bed to be intracranial pressure. Simian creases are Rationale: It isn't within a nurse's scope of Rationale: Once the mother and the fetus are
elevated. present in 40% of the neonates with trisomy 21. practice to perform and interpret a bedside stabilized, ultrasound evaluation of the
71. Answer: (C) Decreased temperature Cystic hygroma is a neck mass that can affect ultrasound under these conditions and without placenta should be done to determine the
Rationale: Temperature instability, especially the airway. specialized training. Observing for pooling of cause of the bleeding. Amniocentesis is
when it results in a low temperature in the 78. Answer: (B) To assess for prolapsed cord straw-colored fluid, checking vaginal discharge contraindicated in placenta previa. A digital or
neonate, may be a sign of infection. The Rationale: After a client has an amniotomy, the with nitrazine paper, and observing for flakes of speculum examination shouldn’t be done as
neonate’s color often changes with an infection nurse should assure that the cord isn't vernix are appropriate assessments for this may lead to severe bleeding or
process but generally becomes ashen or prolapsed and that the baby tolerated the determining whether a client has ruptured hemorrhage. External fetal monitoring won’t
mottled. The neonate with an infection will procedure well. The most effective way to do membranes. detect a placenta previa, although it will detect
usually show a decrease in activity level or this is to check the fetal heart rate. Fetal well- 84. Answer: (C) Monitor partial pressure of oxygen fetal distress, which may result from blood loss
lethargy. being is assessed via a nonstress test. Fetal (Pao2) levels. or placenta separation.
72. Answer: (D) Polycythemia probably due to position is determined by vaginal examination. Rationale: Monitoring PaO2 levels and reducing 89. Answer: (A) Increased tidal volume
chronic fetal hypoxia Artificial rupture of membranes doesn't the oxygen concentration to keep PaO2 within Rationale: A pregnant client breathes deeper,
Rationale: The small-for-gestation neonate is at indicate an imminent delivery. normal limits reduces the risk of retinopathy of which increases the tidal volume of gas moved
risk for developing polycythemia during the 79. Answer: (D) The parents’ interactions with each prematurity in a premature infant receiving in and out of the respiratory tract with each
transitional period in an attempt to decrease other. oxygen. Covering the infant's eyes and breath. The expiratory volume and residual
hypoxia. The neonates are also at increased risk Rationale: Parental interaction will provide the humidifying the oxygen don't reduce the risk of volume decrease as the pregnancy progresses.
for developing hypoglycemia and hypothermia nurse with a good assessment of the stability of retinopathy of prematurity. Because cooling The inspiratory capacity increases during
due to decreased glycogen stores. the family's home life but it has no indication increases the risk of acidosis, the infant should pregnancy. The increased oxygen consumption
73. Answer: (C) Desquamation of the epidermis for parental bonding. Willingness to touch and be kept warm so that his respiratory distress in the pregnant client is 15% to 20% greater
Rationale: Postdate fetuses lose the vernix hold the newborn, expressing interest about isn't aggravated. than in the nonpregnant state.
caseosa, and the epidermis may become the newborn's size, and indicating a desire to 85. Answer: (A) 110 to 130 calories per kg. 90. Answer: (A) Diet
desquamated. These neonates are usually very see the newborn are behaviors indicating Rationale: Calories per kg is the accepted way Rationale: Clients with gestational diabetes are
alert. Lanugo is missing in the postdate parental bonding. of determined appropriate nutritional intake usually managed by diet alone to control their
neonate. 80. Answer: (B) Instructing the client to use two or for a newborn. The recommended calorie glucose intolerance. Oral hypoglycemic drugs
74. Answer: (C) Respiratory depression more peripads to cushion the area requirement is 110 to 130 calories per kg of are contraindicated in pregnancy. Long-acting
Rationale: Magnesium sulfate crosses the Rationale: Using two or more peripads would newborn body weight. This level will maintain a insulin usually isn’t needed for blood glucose
placenta and adverse neonatal effects are do little to reduce the pain or promote perineal consistent blood glucose level and provide control in the client with gestational diabetes.
respiratory depression, hypotonia, and healing. Cold applications, sitz baths, and Kegel enough calories for continued growth and 91. Answer: (D) Seizure
bradycardia. The serum blood sugar isn’t exercises are important measures when the development. Rationale: The anticonvulsant mechanism of
affected by magnesium sulfate. The neonate client has a fourth-degree laceration. 86. Answer: (C) 30 to 32 weeks magnesium is believes to depress seizure foci in
would be floppy, not jittery. 81. Answer: (C) “What is your expected due date?” Rationale: Individual twins usually grow at the the brain and peripheral neuromuscular
75. Answer: (C) Respiratory rate 40 to 60 Rationale: When obtaining the history of a same rate as singletons until 30 to 32 weeks’ blockade. Hypomagnesemia isn’t a
breaths/minute client who may be in labor, the nurse's highest gestation, then twins don’t’ gain weight as complication of preeclampsia. Antihypertensive
Rationale: A respiratory rate 40 to 60 priority is to determine her current status, rapidly as singletons of the same gestational drug other than magnesium are preferred for
breaths/minute is normal for a neonate during particularly her due date, gravidity, and parity. age. The placenta can no longer keep pace with sustained hypertension. Magnesium doesn’t
the transitional period. Nasal flaring, Gravidity and parity affect the duration of labor the nutritional requirements of both fetuses help prevent hemorrhage in preeclamptic
respiratory rate more than 60 breaths/minute, and the potential for labor complications. Later, after 32 weeks, so there’s some growth clients.
and audible grunting are signs of respiratory the nurse should ask about chronic illnesses, retardation in twins if they remain in utero at 92. Answer: (C) I.V. fluids
distress. allergies, and support persons. 38 to 40 weeks. Rationale: A sickle cell crisis during pregnancy is
76. Answer: (C) Keep the cord dry and open to air 82. Answer: (D) Aspirate the neonate’s nose and 87. Answer: (A) conjoined twins usually managed by exchange transfusion
Rationale: Keeping the cord dry and open to air mouth with a bulb syringe. Rationale: The type of placenta that develops in oxygen, and L.V. Fluids. The client usually needs
helps reduce infection and hastens drying. Rationale: The nurse's first action should be to monozygotic twins depends on the time at a stronger analgesic than acetaminophen to
Infants aren’t given tub bath but are sponged clear the neonate's airway with a bulb syringe. which cleavage of the ovum occurs. Cleavage in control the pain of a crisis. Antihypertensive
off until the cord falls off. Petroleum jelly After the airway is clear and the neonate's color conjoined twins occurs more than 13 days after drugs usually aren’t necessary. Diuretic
prevents the cord from drying and encourages improves, the nurse should comfort and calm fertilization. Cleavage that occurs less than 3 wouldn’t be used unless fluid overload resulted.
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93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Neonates of heroin-addicted TEST III - Care of Clients with Physiologic and 6. Nurse Monett is caring for a client recovering
Rationale: Calcium gluconate is the antidote for mothers are physically dependent on the drug Psychosocial Alterations from gastro-intestinal bleeding. The nurse
magnesium toxicity. Ten milliliters of 10% and experience withdrawal when the drug is no should:
calcium gluconate is given L.V. push over 3 to 5 longer supplied. Signs of heroin withdrawal 1. Nurse Michelle should know that the drainage is a. Plan care so the client can receive 8
minutes. Hydralazine is given for sustained include irritability, poor sucking, and normal 4 days after a sigmoid colostomy when hours of uninterrupted sleep each night.
elevated blood pressure in preeclamptic clients. restlessness. Lethargy isn't associated with the stool is: b. Monitor vital signs every 2 hours.
Rho (D) immune globulin is given to women neonatal heroin addiction. A flattened nose, a. Green liquid c. Make sure that the client takes food and
with Rh-negative blood to prevent antibody small eyes, and thin lips are seen in infants with b. Solid formed medications at prescribed intervals.
formation from RH-positive conceptions. fetal alcohol syndrome. Heroin use during c. Loose, bloody d. Provide milk every 2 to 3 hours.
Naloxone is used to correct narcotic toxicity. pregnancy hasn't been linked to specific d. Semiformed
94. Answer: (B) An indurated wheal over 10 mm in congenital anomalies. 7. A male client was on warfarin (Coumadin) before
diameter appears in 48 to 72 hours. 99. Answer: (A) 7th to 9th day postpartum 2. Where would nurse Kristine place the call light admission, and has been receiving heparin I.V.
Rationale: A positive PPD result would be an Rationale: The normal involutional process for a male client with a right-sided brain attack for 2 days. The partial thromboplastin time (PTT)
indurated wheal over 10 mm in diameter that returns the uterus to the pelvic cavity in 7 to 9 and left homonymous hemianopsia? is 68 seconds. What should Nurse Carla do?
appears in 48 to 72 hours. The area must be a days. A significant involutional complication is a. On the client’s right side a. Stop the I.V. infusion of heparin and
raised wheal, not a flat circumcised area to be the failure of the uterus to return to the pelvic b. On the client’s left side notify the physician.
considered positive. cavity within the prescribed time period. This is c. Directly in front of the client b. Continue treatment as ordered.
95. Answer: (C) Pyelonephritis known as subinvolution. d. Where the client like c. Expect the warfarin to increase the PTT.
Rationale The symptoms indicate acute 100. Answer: (B) Uterine atony d. Increase the dosage, because the level is
pyelonephritis, a serious condition in a Rationale: Multiple fetuses, extended labor 3. A male client is admitted to the emergency lower than normal.
pregnant client. UTI symptoms include dysuria, stimulation with oxytocin, and traumatic department following an accident. What are the
urgency, frequency, and suprapubic delivery commonly are associated with uterine first nursing actions of the nurse? 8. A client undergone ileostomy, when should the
tenderness. Asymptomatic bacteriuria doesn’t atony, which may lead to postpartum a. Check respiration, circulation, drainage appliance be applied to the stoma?
cause symptoms. Bacterial vaginosis causes hemorrhage. Uterine inversion may precede or neurological response. a. 24 hours later, when edema has
milky white vaginal discharge but no systemic follow delivery and commonly results from b. Align the spine, check pupils, and check subsided.
symptoms. apparent excessive traction on the umbilical for hemorrhage. b. In the operating room.
96. Answer: (B) Rh-positive fetal blood crosses into cord and attempts to deliver the placenta c. Check respirations, stabilize spine, and c. After the ileostomy begin to function.
maternal blood, stimulating maternal manually. Uterine involution and some uterine check circulation. d. When the client is able to begin self-care
antibodies. discomfort are normal after delivery. d. Assess level of consciousness and procedures.
Rationale: Rh isoimmunization occurs when Rh- circulation.
positive fetal blood cells cross into the maternal 9. A client undergone spinal anesthetic, it will be
circulation and stimulate maternal antibody 4. In evaluating the effect of nitroglycerin, Nurse important that the nurse immediately position
production. In subsequent pregnancies with Rh- Arthur should know that it reduces preload and the client in:
positive fetuses, maternal antibodies may cross relieves angina by: a. On the side, to prevent obstruction of
back into the fetal circulation and destroy the a. Increasing contractility and slowing airway by tongue.
fetal blood cells. heart rate. b. Flat on back.
97. Answer: (C) Supine position b. Increasing AV conduction and heart rate. c. On the back, with knees flexed 15
Rationale: The supine position causes c. Decreasing contractility and oxygen degrees.
compression of the client's aorta and inferior consumption. d. Flat on the stomach, with the head
vena cava by the fetus. This, in turn, inhibits d. Decreasing venous return through turned to the side.
maternal circulation, leading to maternal vasodilation.
hypotension and, ultimately, fetal hypoxia. The 10. While monitoring a male client several hours
other positions promote comfort and aid labor 5. Nurse Patricia finds a female client who is post- after a motor vehicle accident, which
progress. For instance, the lateral, or side-lying, myocardial infarction (MI) slumped on the side assessment data suggest increasing intracranial
position improves maternal and fetal rails of the bed and unresponsive to shaking or pressure?
circulation, enhances comfort, increases shouting. Which is the nurse next action? a. Blood pressure is decreased from
maternal relaxation, reduces muscle tension, a. Call for help and note the time. 160/90 to 110/70.
and eliminates pressure points. The squatting b. Clear the airway b. Pulse is increased from 87 to 95, with an
position promotes comfort by taking advantage c. Give two sharp thumps to the occasional skipped beat.
of gravity. The standing position also takes precordium, and check the pulse. c. The client is oriented when aroused
advantage of gravity and aligns the fetus with d. Administer two quick blows. from sleep, and goes back to sleep
the pelvic angle. immediately.
98. Answer: (B) Irritability and poor sucking.
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d. The client refuses dinner because of 16. Nurse John is caring for a male client receiving weight loss during thyroid replacement During routine assessment, the nurse notices
anorexia. lidocaine I.V. Which factor is the most relevant therapy. Cheyne- Strokes respirations. Cheyne-strokes
to administration of this medication? c. Balance the client’s periods of activity respirations are:
11. Mrs. Cruz, 80 years old is diagnosed with a. Decrease in arterial oxygen saturation and rest. a. A progressively deeper breaths followed
pneumonia. Which of the following symptoms (SaO2) when measured with a pulse d. Encourage the client to be active to by shallower breaths with apneic
may appear first? oximeter. prevent constipation. periods.
a. Altered mental status and dehydration b. Increase in systemic blood pressure. b. Rapid, deep breathing with abrupt
b. Fever and chills c. Presence of premature ventricular 22. Nurse Kris is teaching a client with history of pauses between each breath.
c. Hemoptysis and Dyspnea contractions (PVCs) on a cardiac atherosclerosis. To decrease the risk of c. Rapid, deep breathing and irregular
d. Pleuritic chest pain and cough monitor. atherosclerosis, the nurse should encourage the breathing without pauses.
d. Increase in intracranial pressure (ICP). client to: d. Shallow breathing with an increased
12. A male client has active tuberculosis (TB). Which a. Avoid focusing on his weight. respiratory rate.
of the following symptoms will be exhibit? 17. Nurse Ron is caring for a male client taking an b. Increase his activity level.
a. Chest and lower back pain anticoagulant. The nurse should teach the client c. Follow a regular diet. 28. Nurse Bea is assessing a male client with heart
b. Chills, fever, night sweats, and to: d. Continue leading a high-stress lifestyle. failure. The breath sounds commonly
hemoptysis a. Report incidents of diarrhea. auscultated in clients with heart failure are:
c. Fever of more than 104°F (40°C) and b. Avoid foods high in vitamin K 23. Nurse Greta is working on a surgical floor. Nurse a. Tracheal
nausea c. Use a straight razor when shaving. Greta must logroll a client following a: b. Fine crackles
d. Headache and photophobia d. Take aspirin to pain relief. a. Laminectomy c. Coarse crackles
b. Thoracotomy d. Friction rubs
13. Mark, a 7-year-old client is brought to the 18. Nurse Lhynnette is preparing a site for the c. Hemorrhoidectomy
emergency department. He’s tachypneic and insertion of an I.V. catheter. The nurse should d. Cystectomy. 29. The nurse is caring for Kenneth experiencing an
afebrile and has a respiratory rate of 36 treat excess hair at the site by: acute asthma attack. The client stops wheezing
breaths/minute and has a nonproductive cough. a. Leaving the hair intact 24. A 55-year old client underwent cataract removal and breath sounds aren’t audible. The reason for
He recently had a cold. Form this history; the b. Shaving the area with intraocular lens implant. Nurse Oliver is this change is that:
client may have which of the following c. Clipping the hair in the area giving the client discharge instructions. These a. The attack is over.
conditions? d. Removing the hair with a depilatory. instructions should include which of the b. The airways are so swollen that no air
a. Acute asthma following? cannot get through.
b. Bronchial pneumonia 19. Nurse Michelle is caring for an elderly female a. Avoid lifting objects weighing more than c. The swelling has decreased.
c. Chronic obstructive pulmonary disease with osteoporosis. When teaching the client, the 5 lb (2.25 kg). d. Crackles have replaced wheezes.
(COPD) nurse should include information about which b. Lie on your abdomen when in bed
d. Emphysema major complication: c. Keep rooms brightly lit. 30. Mike with epilepsy is having a seizure. During
a. Bone fracture d. Avoiding straining during bowel the active seizure phase, the nurse should:
14. Marichu was given morphine sulfate for pain. b. Loss of estrogen movement or bending at the waist. a. Place the client on his back remove
She is sleeping and her respiratory rate is 4 c. Negative calcium balance dangerous objects, and insert a bite
breaths/minute. If action isn’t taken quickly, she d. Dowager’s hump 25. George should be taught about testicular block.
might have which of the following reactions? examinations during: b. Place the client on his side, remove
a. Asthma attack 20. Nurse Len is teaching a group of women to a. when sexual activity starts dangerous objects, and insert a bite
b. Respiratory arrest perform BSE. The nurse should explain that the b. After age 69 block.
c. Seizure purpose of performing the examination is to c. After age 40 c. Place the client o his back, remove
d. Wake up on his own discover: d. Before age 20. dangerous objects, and hold down his
a. Cancerous lumps 26. A male client undergone a colon resection. While arms.
15. A 77-year-old male client is admitted for elective b. Areas of thickness or fullness turning him, wound dehiscence with d. Place the client on his side, remove
knee surgery. Physical examination reveals c. Changes from previous examinations. evisceration occurs. Nurse Trish first response is dangerous objects, and protect his head.
shallow respirations but no sign of respiratory d. Fibrocystic masses to:
distress. Which of the following is a normal a. Call the physician 31. After insertion of a cheat tube for a
physiologic change related to aging? 21. When caring for a female client who is being b. Place a saline-soaked sterile dressing on pneumothorax, a client becomes hypotensive
a. Increased elastic recoil of the lungs treated for hyperthyroidism, it is important to: the wound. with neck vein distention, tracheal shift, absent
b. Increased number of functional a. Provide extra blankets and clothing to c. Take a blood pressure and pulse. breath sounds, and diaphoresis. Nurse Amanda
capillaries in the alveoli keep the client warm. d. Pull the dehiscence closed. suspects a tension pneumothorax has occurred.
c. Decreased residual volume b. Monitor the client for signs of What cause of tension pneumothorax should the
d. Decreased vital capacity restlessness, sweating, and excessive 27. Nurse Audrey is caring for a client who has nurse check for?
suffered a severe cerebrovascular accident. a. Infection of the lung.
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b. Kinked or obstructed chest tube tuberculosis (TB). Which of the following clients d. The recipient receives pressure of 126/76 mm Hg, and a
c. Excessive water in the water-seal entering the clinic today most likely to have TB? cyclophosphamide (Cytoxan) for 4 respiratory rate of 22 breaths/ minute.
chamber a. A 16-year-old female high school consecutive days before the procedure. b. The 89-year-old client with end-stage
d. Excessive chest tube drainage student 41. After several days of admission, Francis becomes right-sided heart failure, blood pressure
b. A 33-year-old day-care worker disoriented and complains of frequent of 78/50 mm Hg, and a “do not
32. Nurse Maureen is talking to a male client; the c. A 43-yesr-old homeless man with a headaches. The nurse in-charge first action resuscitate” order
client begins choking on his lunch. He’s coughing history of alcoholism would be: c. The 62-year-old client who was admitted
forcefully. The nurse should: d. A 54-year-old businessman a. Call the physician 1 day ago with thrombophlebitis and is
a. Stand him up and perform the b. Document the patient’s status in his receiving L.V. heparin
abdominal thrust maneuver from 37. Virgie with a positive Mantoux test result will be charts. d. The 75-year-old client who was admitted
behind. sent for a chest X-ray. The nurse is aware that c. Prepare oxygen treatment 1 hour ago with new-onset atrial
b. Lay him down, straddle him, and which of the following reasons this is done? d. Raise the side rails fibrillation and is receiving L.V. dilitiazem
perform the abdominal thrust a. To confirm the diagnosis (Cardizem)
maneuver. b. To determine if a repeat skin test is 42. During routine care, Francis asks the nurse,
c. Leave him to get assistance needed “How can I be anemic if this disease causes 46. Honey, a 23-year old client complains of
d. Stay with him but not intervene at this c. To determine the extent of lesions increased my white blood cell production?” The substernal chest pain and states that her heart
time. d. To determine if this is a primary or nurse in-charge best response would be that the feels like “it’s racing out of the chest”. She
secondary infection increased number of white blood cells (WBC) is: reports no history of cardiac disorders. The
33. Nurse Ron is taking a health history of an 84 year a. Crowd red blood cells nurse attaches her to a cardiac monitor and
old client. Which information will be most useful 38. Kennedy with acute asthma showing inspiratory b. Are not responsible for the anemia. notes sinus tachycardia with a rate of
to the nurse for planning care? and expiratory wheezes and a decreased forced c. Uses nutrients from other cells 136beats/minutes. Breath sounds are clear and
a. General health for the last 10 years. expiratory volume should be treated with which d. Have an abnormally short life span of the respiratory rate is 26 breaths/minutes.
b. Current health promotion activities. of the following classes of medication right cells. Which of the following drugs should the nurse
c. Family history of diseases. away? question the client about using?
d. Marital status. a. Beta-adrenergic blockers 43. Diagnostic assessment of Francis would probably a. Barbiturates
b. Bronchodilators not reveal: b. Opioids
34. When performing oral care on a comatose client, c. Inhaled steroids a. Predominance of lymhoblasts c. Cocaine
Nurse Krina should: d. Oral steroids b. Leukocytosis d. Benzodiazepines
a. Apply lemon glycerin to the client’s lips c. Abnormal blast cells in the bone marrow
at least every 2 hours. 39. Mr. Vasquez 56-year-old client with a 40-year d. Elevated thrombocyte counts 47. A 51-year-old female client tells the nurse in-
b. Brush the teeth with client lying supine. history of smoking one to two packs of cigarettes charge that she has found a painless lump in her
c. Place the client in a side lying position, per day has a chronic cough producing thick 44. Robert, a 57-year-old client with acute arterial right breast during her monthly self-
with the head of the bed lowered. sputum, peripheral edema and cyanotic nail occlusion of the left leg undergoes an examination. Which assessment finding would
d. Clean the client’s mouth with hydrogen beds. Based on this information, he most likely emergency embolectomy. Six hours later, the strongly suggest that this client's lump is
peroxide. has which of the following conditions? nurse isn’t able to obtain pulses in his left foot cancerous?
a. Adult respiratory distress syndrome using Doppler ultrasound. The nurse a. Eversion of the right nipple and mobile
35. A 77-year-old male client is admitted with a (ARDS) immediately notifies the physician, and asks her mass
diagnosis of dehydration and change in mental b. Asthma to prepare the client for surgery. As the nurse b. Nonmobile mass with irregular edges
status. He’s being hydrated with L.V. fluids. c. Chronic obstructive bronchitis enters the client’s room to prepare him, he c. Mobile mass that is soft and easily
When the nurse takes his vital signs, she notes d. Emphysema states that he won’t have any more surgery. delineated
he has a fever of 103°F (39.4°C) a cough Which of the following is the best initial d. Nonpalpable right axillary lymph nodes
producing yellow sputum and pleuritic chest Situation: Francis, age 46 is admitted to the hospital with response by the nurse?
pain. The nurse suspects this client may have diagnosis of Chronic Lymphocytic Leukemia. a. Explain the risks of not having the 48. A 35-year-old client with vaginal cancer asks the
which of the following conditions? surgery nurse, "What is the usual treatment for this type
a. Adult respiratory distress syndrome 40. The treatment for patients with leukemia is bone b. Notifying the physician immediately of cancer?" Which treatment should the nurse
(ARDS) marrow transplantation. Which statement about c. Notifying the nursing supervisor name?
b. Myocardial infarction (MI) bone marrow transplantation is not correct? d. Recording the client’s refusal in the a. Surgery
c. Pneumonia a. The patient is under local anesthesia nurses’ notes b. Chemotherapy
d. Tuberculosis during the procedure c. Radiation
b. The aspirated bone marrow is mixed 45. During the endorsement, which of the following d. Immunotherapy
36. Nurse Oliver is working in an outpatient clinic. with heparin. clients should the on-duty nurse assess first?
He has been alerted that there is an outbreak of c. The aspiration site is the posterior or a. The 58-year-old client who was admitted 49. Cristina undergoes a biopsy of a suspicious
anterior iliac crest. 2 days ago with heart failure, blood lesion. The biopsy report classifies the lesion
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according to the TNM staging system as follows: a. prostate-specific antigen, which is used spinal cord lesion. During the MRI scan, which of 63. A 76-year-old male client had a thromboembolic
TIS, N0, M0. What does this classification mean? to screen for prostate cancer. the following would pose a threat to the client? right stroke; his left arm is swollen. Which of the
a. No evidence of primary tumor, no b. protein serum antigen, which is used to a. The client lies still. following conditions may cause swelling after a
abnormal regional lymph nodes, and no determine protein levels. b. The client asks questions. stroke?
evidence of distant metastasis c. pneumococcal strep antigen, which is a c. The client hears thumping sounds. a. Elbow contracture secondary to
b. Carcinoma in situ, no abnormal regional bacteria that causes pneumonia. d. The client wears a watch and wedding spasticity
lymph nodes, and no evidence of distant d. Papanicolaou-specific antigen, which is band. b. Loss of muscle contraction decreasing
metastasis used to screen for cervical cancer. venous return
c. Can't assess tumor or regional lymph 59. Nurse Cecile is teaching a female client about c. Deep vein thrombosis (DVT) due to
nodes and no evidence of metastasis 54. What is the most important postoperative preventing osteoporosis. Which of the following immobility of the ipsilateral side
d. Carcinoma in situ, no demonstrable instruction that nurse Kate must give a client teaching points is correct? d. Hypoalbuminemia due to protein
metastasis of the regional lymph nodes, who has just returned from the operating room a. Obtaining an X-ray of the bones every 3 escaping from an inflamed glomerulus
and ascending degrees of distant after receiving a subarachnoid block? years is recommended to detect bone
metastasis a. "Avoid drinking liquids until the gag loss. 64. Heberden’s nodes are a common sign of
reflex returns." b. To avoid fractures, the client should osteoarthritis. Which of the following statement
50. Lydia undergoes a laryngectomy to treat b. "Avoid eating milk products for 24 avoid strenuous exercise. is correct about this deformity?
laryngeal cancer. When teaching the client how hours." c. The recommended daily allowance of a. It appears only in men
to care for the neck stoma, the nurse should c. "Notify a nurse if you experience blood calcium may be found in a wide variety b. It appears on the distal interphalangeal
include which instruction? in your urine." of foods. joint
a. "Keep the stoma uncovered." d. "Remain supine for the time specified by d. Obtaining the recommended daily c. It appears on the proximal
b. "Keep the stoma dry." the physician." allowance of calcium requires taking a interphalangeal joint
c. "Have a family member perform stoma calcium supplement. d. It appears on the dorsolateral aspect of
care initially until you get used to the 55. A male client suspected of having colorectal the interphalangeal joint.
procedure." cancer will require which diagnostic study to 60. Before Jacob undergoes arthroscopy, the nurse
d. "Keep the stoma moist." confirm the diagnosis? reviews the assessment findings for 65. Which of the following statements explains the
a. Stool Hematest contraindications for this procedure. Which main difference between rheumatoid arthritis
51. A 37-year-old client with uterine cancer asks the b. Carcinoembryonic antigen (CEA) finding is a contraindication? and osteoarthritis?
nurse, "Which is the most common type of c. Sigmoidoscopy a. Joint pain a. Osteoarthritis is gender-specific,
cancer in women?" The nurse replies that it's d. Abdominal computed tomography (CT) b. Joint deformity rheumatoid arthritis isn’t
breast cancer. Which type of cancer causes the scan c. Joint flexion of less than 50% b. Osteoarthritis is a localized disease
most deaths in women? d. Joint stiffness rheumatoid arthritis is systemic
a. Breast cancer 56. During a breast examination, which finding most c. Osteoarthritis is a systemic disease,
b. Lung cancer strongly suggests that the Luz has breast cancer? 61. Mr. Rodriguez is admitted with severe pain in rheumatoid arthritis is localized
c. Brain cancer a. Slight asymmetry of the breasts. the knees. Which form of arthritis is d. Osteoarthritis has dislocations and
d. Colon and rectal cancer b. A fixed nodular mass with dimpling of characterized by urate deposits and joint pain, subluxations, rheumatoid arthritis
the overlying skin usually in the feet and legs, and occurs primarily doesn’t
52. Antonio with lung cancer develops Horner's c. Bloody discharge from the nipple in men over age 30?
syndrome when the tumor invades the ribs and d. Multiple firm, round, freely movable a. Septic arthritis 66. Mrs. Cruz uses a cane for assistance in walking.
affects the sympathetic nerve ganglia. When masses that change with the menstrual b. Traumatic arthritis Which of the following statements is true about
assessing for signs and symptoms of this cycle c. Intermittent arthritis a cane or other assistive devices?
syndrome, the nurse should note: d. Gouty arthritis a. A walker is a better choice than a cane.
a. miosis, partial eyelid ptosis, and 57. A female client with cancer is being evaluated b. The cane should be used on the affected
anhidrosis on the affected side of the for possible metastasis. Which of the following is 62. A heparin infusion at 1,500 unit/hour is ordered side
face. one of the most common metastasis sites for for a 64-year-old client with stroke in evolution. c. The cane should be used on the
b. chest pain, dyspnea, cough, weight loss, cancer cells? The infusion contains 25,000 units of heparin in unaffected side
and fever. a. Liver 500 ml of saline solution. How many milliliters d. A client with osteoarthritis should be
c. arm and shoulder pain and atrophy of b. Colon per hour should be given? encouraged to ambulate without the
arm and hand muscles, both on the c. Reproductive tract a. 15 ml/hour cane
affected side. d. White blood cells (WBCs) b. 30 ml/hour
d. hoarseness and dysphagia. c. 45 ml/hour 67. A male client with type 1 diabetes is scheduled
58. Nurse Mandy is preparing a client for magnetic d. 50 ml/hour to receive 30 U of 70/30 insulin. There is no
53. Vic asks the nurse what PSA is. The nurse should resonance imaging (MRI) to confirm or rule out a 70/30 insulin available. As a substitution, the
reply that it stands for: nurse may give the client:
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a. 9 U regular insulin and 21 U neutral c. Restricting fluids 78. Francis with anemia has been admitted to the c. Administer the antidote for penicillin, as
protamine Hagedorn (NPH). d. Administering glucose-containing I.V. medical-surgical unit. Which assessment findings prescribed, and continue to monitor the
b. 21 U regular insulin and 9 U NPH. fluids as ordered are characteristic of iron-deficiency anemia? client's vital signs.
c. 10 U regular insulin and 20 U NPH. a. Nights sweats, weight loss, and diarrhea d. Insert an indwelling urinary catheter and
d. 20 U regular insulin and 10 U NPH. 73. A female client tells nurse Nikki that she has b. Dyspnea, tachycardia, and pallor begin to infuse I.V. fluids as ordered.
been working hard for the last 3 months to c. Nausea, vomiting, and anorexia
68. Nurse Len should expect to administer which control her type 2 diabetes mellitus with diet d. Itching, rash, and jaundice 83. Mr. Marquez with rheumatoid arthritis is about
medication to a client with gout? and exercise. To determine the effectiveness of to begin aspirin therapy to reduce inflammation.
a. aspirin the client's efforts, the nurse should check: 79. In teaching a female client who is HIV-positive When teaching the client about aspirin, the
b. furosemide (Lasix) a. urine glucose level. about pregnancy, the nurse would know more nurse discusses adverse reactions to prolonged
c. colchicines b. fasting blood glucose level. teaching is necessary when the client says: aspirin therapy. These include:
d. calcium gluconate (Kalcinate) c. serum fructosamine level. a. The baby can get the virus from my a. weight gain.
d. glycosylated hemoglobin level. placenta." b. fine motor tremors.
69. Mr. Domingo with a history of hypertension is b. "I'm planning on starting on birth control c. respiratory acidosis.
diagnosed with primary hyperaldosteronism. 74. Nurse Trinity administered neutral protamine pills." d. bilateral hearing loss.
This diagnosis indicates that the client's Hagedorn (NPH) insulin to a diabetic client at 7 c. "Not everyone who has the virus gives
hypertension is caused by excessive hormone a.m. At what time would the nurse expect the birth to a baby who has the virus." 84. A 23-year-old client is diagnosed with human
secretion from which of the following glands? client to be most at risk for a hypoglycemic d. "I'll need to have a C-section if I become immunodeficiency virus (HIV). After recovering
a. Adrenal cortex reaction? pregnant and have a baby." from the initial shock of the diagnosis, the client
b. Pancreas a. 10:00 am expresses a desire to learn as much as possible
c. Adrenal medulla b. Noon 80. When preparing Judy with acquired about HIV and acquired immunodeficiency
d. Parathyroid c. 4:00 pm immunodeficiency syndrome (AIDS) for syndrome (AIDS). When teaching the client
d. 10:00 pm discharge to the home, the nurse should be sure about the immune system, the nurse states that
70. For a diabetic male client with a foot ulcer, the to include which instruction? adaptive immunity is provided by which type of
doctor orders bed rest, a wet-to-dry dressing 75. The adrenal cortex is responsible for producing a. "Put on disposable gloves before white blood cell?
change every shift, and blood glucose which substances? bathing." a. Neutrophil
monitoring before meals and bedtime. Why are a. Glucocorticoids and androgens b. "Sterilize all plates and utensils in boiling b. Basophil
wet-to-dry dressings used for this client? b. Catecholamines and epinephrine water." c. Monocyte
a. They contain exudate and provide a c. Mineralocorticoids and catecholamines c. "Avoid sharing such articles as d. Lymphocyte
moist wound environment. d. Norepinephrine and epinephrine toothbrushes and razors."
b. They protect the wound from d. "Avoid eating foods from serving dishes 85. In an individual with Sjögren's syndrome, nursing
mechanical trauma and promote 76. On the third day after a partial thyroidectomy, shared by other family members." care should focus on:
healing. Proserfina exhibits muscle twitching and a. moisture replacement.
c. They debride the wound and promote hyperirritability of the nervous system. When 81. Nurse Marie is caring for a 32-year-old client b. electrolyte balance.
healing by secondary intention. questioned, the client reports numbness and admitted with pernicious anemia. Which set of c. nutritional supplementation.
d. They prevent the entrance of tingling of the mouth and fingertips. Suspecting findings should the nurse expect when assessing d. arrhythmia management.
microorganisms and minimize wound a life-threatening electrolyte disturbance, the the client?
discomfort. nurse notifies the surgeon immediately. Which a. Pallor, bradycardia, and reduced pulse 86. During chemotherapy for lymphocytic leukemia,
electrolyte disturbance most commonly follows pressure Mathew develops abdominal pain, fever, and
71. Nurse Zeny is caring for a client in acute thyroid surgery? b. Pallor, tachycardia, and a sore tongue "horse barn" smelling diarrhea. It would be most
addisonian crisis. Which laboratory data would a. Hypocalcemia c. Sore tongue, dyspnea, and weight gain important for the nurse to advise the physician
the nurse expect to find? b. Hyponatremia d. Angina, double vision, and anorexia to order:
a. Hyperkalemia c. Hyperkalemia a. enzyme-linked immunosuppressant
b. Reduced blood urea nitrogen (BUN) d. Hypermagnesemia 82. After receiving a dose of penicillin, a client assay (ELISA) test.
c. Hypernatremia develops dyspnea and hypotension. Nurse b. electrolyte panel and hemogram.
d. Hyperglycemia 77. Which laboratory test value is elevated in clients Celestina suspects the client is experiencing c. stool for Clostridium difficile test.
who smoke and can't be used as a general anaphylactic shock. What should the nurse do d. flat plate X-ray of the abdomen.
72. A client is admitted for treatment of the indicator of cancer? first?
syndrome of inappropriate antidiuretic hormone a. Acid phosphatase level a. Page an anesthesiologist immediately 87. A male client seeks medical evaluation for
(SIADH). Which nursing intervention is b. Serum calcitonin level and prepare to intubate the client. fatigue, night sweats, and a 20-lb weight loss in 6
appropriate? c. Alkaline phosphatase level b. Administer epinephrine, as prescribed, weeks. To confirm that the client has been
a. Infusing I.V. fluids rapidly as ordered d. Carcinoembryonic antigen level and prepare to intubate the client if infected with the human immunodeficiency virus
b. Encouraging increased oral intake necessary. (HIV), the nurse expects the physician to order:
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a. E-rosette immunofluorescence. d. A client with rheumatoid arthritis who d. Insert a Foley catheter takes small steps while balancing on the
b. quantification of T-lymphocytes. states, “I am having trouble sleeping.” walker.
c. enzyme-linked immunosorbent assay 96. Nurse Jannah teaches an elderly client with d. The client slides the walker 18 inches
(ELISA). 92. Nurse Sarah is caring for clients on the surgical right-sided weakness how to use cane. Which of forward, then takes small steps while
d. Western blot test with ELISA. floor and has just received report from the the following behaviors, if demonstrated by the holding onto the walker for balance.
previous shift. Which of the following clients client to the nurse, indicates that the teaching
88. A complete blood count is commonly performed should the nurse see first? was effective? 99. Nurse Deric is supervising a group of elderly
before a Joe goes into surgery. What does this a. A 35-year-old admitted three hours ago a. The client holds the cane with his right clients in a residential home setting. The nurse
test seek to identify? with a gunshot wound; 1.5 cm area of hand, moves the can forward followed knows that the elderly are at greater risk of
a. Potential hepatic dysfunction indicated dark drainage noted on the dressing. by the right leg, and then moves the left developing sensory deprivation for what reason?
by decreased blood urea nitrogen (BUN) b. A 43-year-old who had a mastectomy leg. a. Increased sensitivity to the side effects
and creatinine levels two days ago; 23 ml of serosanguinous b. The client holds the cane with his right of medications.
b. Low levels of urine constituents normally fluid noted in the Jackson-Pratt drain. hand, moves the cane forward followed b. Decreased visual, auditory, and
excreted in the urine c. A 59-year-old with a collapsed lung due by his left leg, and then moves the right gustatory abilities.
c. Abnormally low hematocrit (HCT) and to an accident; no drainage noted in the leg. c. Isolation from their families and familiar
hemoglobin (Hb) levels previous eight hours. c. The client holds the cane with his left surroundings.
d. Electrolyte imbalance that could affect d. A 62-year-old who had an abdominal- hand, moves the cane forward followed d. Decrease musculoskeletal function and
the blood's ability to coagulate properly perineal resection three days ago; client by the right leg, and then moves the left mobility.
complaints of chills. leg.
89. While monitoring a client for the development d. The client holds the cane with his left 100. A male client with emphysema becomes
of disseminated intravascular coagulation (DIC), 93. Nurse Eve is caring for a client who had a hand, moves the cane forward followed restless and confused. What step should
the nurse should take note of what assessment thyroidectomy 12 hours ago for treatment of by his left leg, and then moves the right nurse Jasmine take next?
parameters? Grave’s disease. The nurse would be most leg. a. Encourage the client to perform pursed
a. Platelet count, prothrombin time, and concerned if which of the following was lip breathing.
partial thromboplastin time observed? 97. An elderly client is admitted to the nursing home b. Check the client’s temperature.
b. Platelet count, blood glucose levels, and a. Blood pressure 138/82, respirations 16, setting. The client is occasionally confused and c. Assess the client’s potassium level.
white blood cell (WBC) count oral temperature 99 degrees Fahrenheit. her gait is often unsteady. Which of the d. Increase the client’s oxygen flow rate.
c. Thrombin time, calcium levels, and b. The client supports his head and neck following actions, if taken by the nurse, is most
potassium levels when turning his head to the right. appropriate?
d. Fibrinogen level, WBC, and platelet c. The client spontaneously flexes his wrist a. Ask the woman’s family to provide
count when the blood pressure is obtained. personal items such as photos or
d. The client is drowsy and complains of mementos.
90. When taking a dietary history from a newly sore throat. b. Select a room with a bed by the door so
admitted female client, Nurse Len should the woman can look down the hall.
remember that which of the following foods is a 94. Julius is admitted with complaints of severe pain c. Suggest the woman eat her meals in the
common allergen? in the lower right quadrant of the abdomen. To room with her roommate.
a. Bread assist with pain relief, the nurse should take d. Encourage the woman to ambulate in
b. Carrots which of the following actions? the halls twice a day.
c. Orange a. Encourage the client to change positions
d. Strawberries frequently in bed. 98. Nurse Evangeline teaches an elderly client how
b. Administer Demerol 50 mg IM q 4 hours to use a standard aluminum walker. Which of
91. Nurse John is caring for clients in the outpatient and PRN. the following behaviors, if demonstrated by the
clinic. Which of the following phone calls should c. Apply warmth to the abdomen with a client, indicates that the nurse’s teaching was
the nurse return first? heating pad. effective?
a. A client with hepatitis A who states, “My d. Use comfort measures and pillows to a. The client slowly pushes the walker
arms and legs are itching.” position the client. forward 12 inches, then takes small
b. A client with cast on the right leg who steps forward while leaning on the
states, “I have a funny feeling in my right 95. Nurse Tina prepares a client for peritoneal walker.
leg.” dialysis. Which of the following actions should b. The client lifts the walker, moves it
c. A client with osteomyelitis of the spine the nurse take first? forward 10 inches, and then takes
who states, “I am so nauseous that I a. Assess for a bruit and a thrill. several small steps forward.
can’t eat.” b. Warm the dialysate solution. c. The client supports his weight on the
c. Position the client on the left side. walker while advancing it forward, then
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Answers and Rationale – Care of Clients with these enzymes is begun at once. Skin exposed capillaries in the alveoli, and an increased in hyperthyroidism are hyperactive and complain
Physiologic and Psychosocial Alterations to these enzymes even for a short time residual volume. of feeling very warm.
becomes reddened, painful, and excoriated. 16. Answer: (C) Presence of premature ventricular 22. Answer: (B) Increase his activity level.
1. Answer: (C) Loose, bloody 9. Answer: (B) Flat on back. contractions (PVCs) on a cardiac monitor. Rationale: The client should be encouraged to
Rationale: Normal bowel function and soft- Rationale: To avoid the complication of a Rationale: Lidocaine drips are commonly used increase his activity level. aintaining an ideal
formed stool usually do not occur until around painful spinal headache that can last for to treat clients whose arrhythmias haven’t weight; following a low-cholesterol, low
the seventh day following surgery. The stool several days, the client is kept in flat in a been controlled with oral medication and who sodium diet; and avoiding stress are all
consistency is related to how much water is supine position for approximately 4 to 12 are having PVCs that are visible on the cardiac important factors in decreasing the risk of
being absorbed. hours postoperatively. Headaches are monitor. SaO2, blood pressure, and ICP are atherosclerosis.
2. Answer: (A) On the client’s right side believed to be causes by the seepage of important factors but aren’t as significant as 23. Answer: (A) Laminectomy
Rationale: The client has left visual field cerebral spinal fluid from the puncture site. By PVCs in the situation. Rationale: The client who has had spinal
blindness. The client will see only from the keeping the client flat, cerebral spinal fluid 17. Answer: (B) Avoid foods high in vitamin K surgery, such as laminectomy, must be log
right side. pressures are equalized, which avoids trauma Rationale: The client should avoid consuming rolled to keep the spinal column straight when
3. Answer: (C) Check respirations, stabilize spine, to the neurons. large amounts of vitamin K because vitamin K turning. Thoracotomy and cystectomy may
and check circulation 10. Answer: (C) The client is oriented when can interfere with anticoagulation. The client turn themselves or may be assisted into a
Rationale: Checking the airway would be aroused from sleep, and goes back to sleep may need to report diarrhea, but isn’t effect comfortable position. Under normal
priority, and a neck injury should be immediately. of taking an anticoagulant. An electric razor- circumstances, hemorrhoidectomy is an
suspected. Rationale: This finding suggest that the level not a straight razor-should be used to prevent outpatient procedure, and the client may
4. Answer: (D) Decreasing venous return through of consciousness is decreasing. cuts that cause bleeding. Aspirin may increase resume normal activities immediately after
vasodilation. 11. Answer: (A) Altered mental status and the risk of bleeding; acetaminophen should be surgery.
Rationale: The significant effect of dehydration used to pain relief. 24. Answer: (D) Avoiding straining during bowel
nitroglycerin is vasodilation and decreased Rationale: Fever, chills, hemortysis, dyspnea, 18. Answer: (C) Clipping the hair in the area movement or bending at the waist.
venous return, so the heart does not have to cough, and pleuritic chest pain are the Rationale: Hair can be a source of infection Rationale: The client should avoid straining,
work hard. common symptoms of pneumonia, but elderly and should be removed by clipping. Shaving lifting heavy objects, and coughing harshly
5. Answer: (A) Call for help and note the time. clients may first appear with only an altered the area can cause skin abrasions and because these activities increase intraocular
Rationale: Having established, by stimulating lentil status and dehydration due to a blunted depilatories can irritate the skin. pressure. Typically, the client is instructed to
the client, that the client is unconscious rather immune response. 19. Answer: (A) Bone fracture avoid lifting objects weighing more than 15 lb
than sleep, the nurse should immediately call 12. Answer: (B) Chills, fever, night sweats, and Rationale: Bone fracture is a major (7kg) – not 5lb. instruct the client when lying
for help. This may be done by dialing the hemoptysis complication of osteoporosis that results in bed to lie on either the side or back. The
operator from the client’s phone and giving Rationale: Typical signs and symptoms are when loss of calcium and phosphate increased client should avoid bright light by wearing
the hospital code for cardiac arrest and the chills, fever, night sweats, and hemoptysis. the fragility of bones. Estrogen deficiencies sunglasses.
client’s room number to the operator, of if the Chest pain may be present from coughing, but result from menopause-not osteoporosis. 25. Answer: (D) Before age 20.
phone is not available, by pulling the isn’t usual. Clients with TB typically have low- Calcium and vitamin D supplements may be Rationale: Testicular cancer commonly occurs
emergency call button. Noting the time is grade fevers, not higher than 102°F (38.9°C). used to support normal bone metabolism, But in men between ages 20 and 30. A male client
important baseline information for cardiac Nausea, headache, and photophobia aren’t a negative calcium balance isn’t a should be taught how to perform testicular
arrest procedure usual TB symptoms. complication of osteoporosis. Dowager’s self- examination before age 20, preferably
6. Answer: (C) Make sure that the client takes 13. Answer:(A) Acute asthma hump results from bone fractures. It develops when he enters his teens.
food and medications at prescribed intervals. Rationale: Based on the client’s history and when repeated vertebral fractures increase 26. Answer: (B) Place a saline-soaked sterile
Rationale: Food and drug therapy will prevent symptoms, acute asthma is the most likely spinal curvature. dressing on the wound.
the accumulation of hydrochloric acid, or will diagnosis. He’s unlikely to have bronchial 20. Answer: (C) Changes from previous Rationale: The nurse should first place saline-
neutralize and buffer the acid that does pneumonia without a productive cough and examinations. soaked sterile dressings on the open wound to
accumulate. fever and he’s too young to have developed Rationale: Women are instructed to examine prevent tissue drying and possible infection.
7. Answer: (B) Continue treatment as ordered. (COPD) and emphysema. themselves to discover changes that have Then the nurse should call the physician and
Rationale: The effects of heparin are 14. Answer: (B) Respiratory arrest occurred in the breast. Only a physician can take the client’s vital signs. The dehiscence
monitored by the PTT is normally 30 to 45 Rationale: Narcotics can cause respiratory diagnose lumps that are cancerous, areas of needs to be surgically closed, so the nurse
seconds; the therapeutic level is 1.5 to 2 times arrest if given in large quantities. It’s unlikely thickness or fullness that signal the presence should never try to close it.
the normal level. the client will have asthma attack or a seizure of a malignancy, or masses that are fibrocystic 27. Answer: (A) A progressively deeper breaths
8. Answer: (B) In the operating room. or wake up on his own. as opposed to malignant. followed by shallower breaths with apneic
Rationale: The stoma drainage bag is applied 15. Answer: (D) Decreased vital capacity 21. Answer: (C) Balance the client’s periods of periods.
in the operating room. Drainage from the Rationale: Reduction in vital capacity is a activity and rest. Rationale: Cheyne-Strokes respirations are
ileostomy contains secretions that are rich in normal physiologic change includes decreased Rationale: A client with hyperthyroidism breaths that become progressively deeper
digestive enzymes and highly irritating to the elastic recoil of the lungs, fewer functional needs to be encouraged to balance periods of fallowed by shallower respirations with
skin. Protection of the skin from the effects of activity and rest. Many clients with apneas periods. Biot’s respirations are rapid,
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deep breathing with abrupt pauses between Rationale: Recognizing an individual’s positive Rationale: Bronchodilators are the first line of Rationale: The client with atrial fibrillation has
each breath, and equal depth between each health measures is very useful. General health treatment for asthma because broncho- the greatest potential to become unstable and
breath. Kussmaul’s respirationa are rapid, in the previous 10 years is important, constriction is the cause of reduced airflow. is on L.V. medication that requires close
deep breathing without pauses. Tachypnea is however, the current activities of an 84 year Beta- adrenergic blockers aren’t used to treat monitoring. After assessing this client, the
shallow breathing with increased respiratory old client are most significant in planning care. asthma and can cause broncho- constriction. nurse should assess the client with
rate. Family history of disease for a client in later Inhaled oral steroids may be given to reduce thrombophlebitis who is receiving a heparin
28. Answer: (B) Fine crackles years is of minor significance. Marital status the inflammation but aren’t used for infusion, and then the 58- year-old client
Rationale: Fine crackles are caused by fluid in information may be important for discharge emergency relief. admitted 2 days ago with heart failure (his
the alveoli and commonly occur in clients with planning but is not as significant for 39. Answer: (C) Chronic obstructive bronchitis signs and symptoms are resolving and don’t
heart failure. Tracheal breath sounds are addressing the immediate medical problem. Rationale: Because of this extensive smoking require immediate attention). The lowest
auscultated over the trachea. Coarse crackles 34. Answer: (C) Place the client in a side lying history and symptoms the client most likely priority is the 89-year-old with end-stage
are caused by secretion accumulation in the position, with the head of the bed lowered. has chronic obstructive bronchitis. Client with right-sided heart failure, who requires time-
airways. Friction rubs occur with pleural Rationale: The client should be positioned in a ARDS have acute symptoms of hypoxia and consuming supportive measures.
inflammation. side-lying position with the head of the bed typically need large amounts of oxygen. 46. Answer: (C) Cocaine
29. Answer: (B) The airways are so swollen that no lowered to prevent aspiration. A small amount Clients with asthma and emphysema tend not Rationale: Because of the client’s age and
air cannot get through of toothpaste should be used and the mouth to have chronic cough or peripheral edema. negative medical history, the nurse should
Rationale: During an acute attack, wheezing swabbed or suctioned to remove pooled 40. Answer: (A) The patient is under local question her about cocaine use. Cocaine
may stop and breath sounds become secretions. Lemon glycerin can be drying if anesthesia during the procedure Rationale: increases myocardial oxygen consumption and
inaudible because the airways are so swollen used for extended periods. Brushing the teeth Before the procedure, the patient is can cause coronary artery spasm, leading to
that air can’t get through. If the attack is over with the client lying supine may lead to administered with drugs that would help to tachycardia, ventricular fibrillation, myocardial
and swelling has decreased, there would be aspiration. Hydrogen peroxide is caustic to prevent infection and rejection of the ischemia, and myocardial infarction.
no more wheezing and less emergent concern. tissues and should not be used. transplanted cells such as antibiotics, Barbiturate overdose may trigger respiratory
Crackles do not replace wheezes during an 35. Answer: (C) Pneumonia cytotoxic, and corticosteroids. During the depression and slow pulse. Opioids can cause
acute asthma attack. Rationale: Fever productive cough and transplant, the patient is placed under general marked respiratory depression, while
30. Answer: (D) Place the client on his side, pleuritic chest pain are common signs and anesthesia. benzodiazepines can cause drowsiness and
remove dangerous objects, and protect his symptoms of pneumonia. The client with 41. Answer: (D) Raise the side rails confusion.
head. ARDS has dyspnea and hypoxia with Rationale: A patient who is disoriented is at 47. Answer: (B) Nonmobile mass with irregular
Rationale: During the active seizure phase, worsening hypoxia over time, if not treated risk of falling out of bed. The initial action of edges
initiate precautions by placing the client on his aggressively. Pleuritic chest pain varies with the nurse should be raising the side rails to Rationale: Breast cancer tumors are fixed,
side, removing dangerous objects, and respiration, unlike the constant chest pain ensure patients safety. hard, and poorly delineated with irregular
protecting his head from injury. A bite block during an MI; so this client most likely isn’t 42. Answer: (A) Crowd red blood cells edges. A mobile mass that is soft and easily
should never be inserted during the active having an MI. the client with TB typically has a Rationale: The excessive production of white delineated is most often a fluid-filled benign
seizure phase. Insertion can break the teeth cough producing blood-tinged sputum. A blood cells crowd out red blood cells cyst. Axillary lymph nodes may or may not be
and lead to aspiration. sputum culture should be obtained to confirm production which causes anemia to occur. palpable on initial detection of a cancerous
31. Answer: (B) Kinked or obstructed chest tube the nurse’s suspicions. 43. Answer: (B) Leukocytosis mass. Nipple retraction — not eversion —
Rationales: Kinking and blockage of the chest 36. Answer: (C) A 43-yesr-old homeless man with Rationale: Chronic Lymphocytic leukemia (CLL) may be a sign of cancer.
tube is a common cause of a tension a history of alcoholism is characterized by increased production of 48. Answer: (C) Radiation
pneumothorax. Infection and excessive Rationale: Clients who are economically leukocytes and lymphocytes resulting in Rationale: The usual treatment for vaginal
drainage won’t cause a tension disadvantaged, malnourished, and have leukocytosis, and proliferation of these cells cancer is external or intravaginal radiation
pneumothorax. Excessive water won’t affect reduced immunity, such as a client with a within the bone marrow, spleen and liver. therapy. Less often, surgery is performed.
the chest tube drainage. history of alcoholism, are at extremely high 44. Answer: (A) Explain the risks of not having the Chemotherapy typically is prescribed only if
32. Answer: (D) Stay with him but not intervene at risk for developing TB. A high school student, surgery vaginal cancer is diagnosed in an early stage,
this time. day- care worker, and businessman probably Rationale: The best initial response is to which is rare. Immunotherapy isn't used to
Rationale: If the client is coughing, he should have a much low risk of contracting TB. explain the risks of not having the surgery. If treat vaginal cancer.
be able to dislodge the object or cause a 37. Answer: (C ) To determine the extent of the client understands the risks but still 49. Answer: (B) Carcinoma in situ, no abnormal
complete obstruction. If complete obstruction lesions refuses the nurse should notify the physician regional lymph nodes, and no evidence of
occurs, the nurse should perform the Rationale: If the lesions are large enough, the and the nurse supervisor and then record the distant metastasis
abdominal thrust maneuver with the client chest X-ray will show their presence in the client’s refusal in the nurses’ notes. Rationale: TIS, N0, M0 denotes carcinoma in
standing. If the client is unconscious, she lungs. Sputum culture confirms the diagnosis. 45. Answer: (D) The 75-year-old client who was situ, no abnormal regional lymph nodes, and
should lay him down. A nurse should never There can be false-positive and false-negative admitted 1 hour ago with new-onset atrial no evidence of distant metastasis. No
leave a choking client alone. skin test results. A chest X-ray can’t determine fibrillation and is receiving L.V. dilitiazem evidence of primary tumor, no abnormal
33. Answer: (B) Current health promotion if this is a primary or secondary infection. (Cardizem) regional lymph nodes, and no evidence of
activities 38. Answer: (B) Bronchodilators distant metastasis is classified as T0, N0, M0. If
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the tumor and regional lymph nodes can't be nurse should instruct the client to remain though not always, possible to get the Rationale: Heberden’s nodes appear on the
assessed and no evidence of metastasis exists, supine for the time specified by the physician. recommended daily requirement in the foods distal interphalageal joint on both men and
the lesion is classified as TX, NX, M0. A Local anesthetics used in a subarachnoid block we eat. Supplements are available but not women. Bouchard’s node appears on the
progressive increase in tumor size, no don't alter the gag reflex. No interactions always necessary. Osteoporosis doesn't show dorsolateral aspect of the proximal
demonstrable metastasis of the regional between local anesthetics and food occur. up on ordinary X-rays until 30% of the bone interphalangeal joint.
lymph nodes, and ascending degrees of Local anesthetics don't cause hematuria. loss has occurred. Bone densitometry can 65. Answer: (B) Osteoarthritis is a localized
distant metastasis is classified as T1, T2, T3, or 55. Answer: (C) Sigmoidoscopy detect bone loss of 3% or less. This test is disease rheumatoid arthritis is systemic
T4; N0; and M1, M2, or M3. Rationale: Used to visualize the lower GI tract, sometimes recommended routinely for Rationale: Osteoarthritis is a localized disease,
50. Answer: (D) "Keep the stoma moist." sigmoidoscopy and proctoscopy aid in the women over 35 who are at risk. Strenuous rheumatoid arthritis is systemic. Osteoarthritis
Rationale: The nurse should instruct the client detection of two-thirds of all colorectal exercise won't cause fractures. isn’t gender-specific, but rheumatoid arthritis
to keep the stoma moist, such as by applying a cancers. Stool Hematest detects blood, which 60. Answer: (C) Joint flexion of less than 50% is. Clients have dislocations and subluxations
thin layer of petroleum jelly around the edges, is a sign of colorectal cancer; however, the Rationale: Arthroscopy is contraindicated in in both disorders.
because a dry stoma may become irritated. test doesn't confirm the diagnosis. CEA may clients with joint flexion of less than 50% 66. Answer: (C) The cane should be used on the
The nurse should recommend placing a stoma be elevated in colorectal cancer but isn't because of technical problems in inserting the unaffected side
bib over the stoma to filter and warm air considered a confirming test. An abdominal CT instrument into the joint to see it clearly. Rationale: A cane should be used on the
before it enters the stoma. The client should scan is used to stage the presence of Other contraindications for this procedure unaffected side. A client with osteoarthritis
begin performing stoma care without colorectal cancer. include skin and wound infections. Joint pain should be encouraged to ambulate with a
assistance as soon as possible to gain 56. Answer: (B) A fixed nodular mass with may be an indication, not a contraindication, cane, walker, or other assistive device as
independence in self-care activities. dimpling of the overlying skin for arthroscopy. Joint deformity and joint needed; their use takes weight and stress off
51. Answer: (B) Lung cancer Rationale: A fixed nodular mass with dimpling stiffness aren't contraindications for this joints.
Rationale: Lung cancer is the most deadly type of the overlying skin is common during late procedure. 67. Answer: (A) a. 9 U regular insulin and 21 U
of cancer in both women and men. Breast stages of breast cancer. Many women have 61. Answer: (D) Gouty arthritis neutral protamine Hagedorn (NPH).
cancer ranks second in women, followed (in slightly asymmetrical breasts. Bloody nipple Rationale: Gouty arthritis, a metabolic disease, Rationale: A 70/30 insulin preparation is 70%
descending order) by colon and rectal cancer, discharge is a sign of intraductal papilloma, a is characterized by urate deposits and pain in NPH and 30% regular insulin. Therefore, a
pancreatic cancer, ovarian cancer, uterine benign condition. Multiple firm, round, freely the joints, especially those in the feet and correct substitution requires mixing 21 U of
cancer, lymphoma, leukemia, liver cancer, movable masses that change with the legs. Urate deposits don't occur in septic or NPH and 9 U of regular insulin. The other
brain cancer, stomach cancer, and multiple menstrual cycle indicate fibrocystic breasts, a traumatic arthritis. Septic arthritis results from choices are incorrect dosages for the
myeloma. benign condition. bacterial invasion of a joint and leads to prescribed insulin.
52. Answer: (A) miosis, partial eyelid ptosis, and 57. Answer: (A) Liver inflammation of the synovial lining. Traumatic 68. Answer: (C) colchicines
anhidrosis on the affected side of the face. Rationale: The liver is one of the five most arthritis results from blunt trauma to a joint or Rationale: A disease characterized by joint
Rationale: Horner's syndrome, which occurs common cancer metastasis sites. The others ligament. Intermittent arthritis is a rare, inflammation (especially in the great toe),
when a lung tumor invades the ribs and are the lymph nodes, lung, bone, and brain. benign condition marked by regular, recurrent gout is caused by urate crystal deposits in the
affects the sympathetic nerve ganglia, is The colon, reproductive tract, and WBCs are joint effusions, especially in the knees. joints. The physician prescribes colchicine to
characterized by miosis, partial eyelid ptosis, occasional metastasis sites. 62. Answer: (B) 30 ml/hou reduce these deposits and thus ease joint
and anhidrosis on the affected side of the 58. Answer: (D) The client wears a watch and Rationale: An infusion prepared with 25,000 inflammation. Although aspirin is used to
face. Chest pain, dyspnea, cough, weight loss, wedding band. units of heparin in 500 ml of saline solution reduce joint inflammation and pain in clients
and fever are associated with pleural tumors. Rationale: During an MRI, the client should yields 50 units of heparin per milliliter of with osteoarthritis and rheumatoid arthritis, it
Arm and shoulder pain and atrophy of the arm wear no metal objects, such as jewelry, solution. The equation is set up as 50 units isn't indicated for gout because it has no
and hand muscles on the affected side suggest because the strong magnetic field can pull on times X (the unknown quantity) equals 1,500 effect on urate crystal formation. Furosemide,
Pancoast's tumor, a lung tumor involving the them, causing injury to the client and (if they units/hour, X equals 30 ml/hour. a diuretic, doesn't relieve gout. Calcium
first thoracic and eighth cervical nerves within fly off) to others. The client must lie still 63. Answer: (B) Loss of muscle contraction gluconate is used to reverse a negative
the brachial plexus. Hoarseness in a client during the MRI but can talk to those decreasing venous return calcium balance and relieve muscle cramps,
with lung cancer suggests that the tumor has performing the test by way of the microphone Rationale: In clients with hemiplegia or not to treat gout.
extended to the recurrent laryngeal nerve; inside the scanner tunnel. The client should hemiparesis loss of muscle contraction 69. Answer: (A) Adrenal cortex
dysphagia suggests that the lung tumor is hear thumping sounds, which are caused by decreases venous return and may cause Rationale: Excessive secretion of aldosterone
compressing the esophagus. the sound waves thumping on the magnetic swelling of the affected extremity. in the adrenal cortex is responsible for the
53. 53. Answer: (A) prostate-specific antigen, field. Contractures, or bony calcifications may occur client's hypertension. This hormone acts on
which is used to screen for prostate cancer. 59. Answer: (C) The recommended daily with a stroke, but don’t appear with swelling. the renal tubule, where it promotes
Rationale: PSA stands for prostate-specific allowance of calcium may be found in a wide DVT may develop in clients with a stroke but is reabsorption of sodium and excretion of
antigen, which is used to screen for prostate variety of foods. more likely to occur in the lower extremities. potassium and hydrogen ions. The pancreas
cancer. The other answers are incorrect. Rationale: Premenopausal women require A stroke isn’t linked to protein loss. mainly secretes hormones involved in fuel
54. Answer: (D) "Remain supine for the time 1,000 mg of calcium per day. Postmenopausal 64. Answer: (B) It appears on the distal metabolism. The adrenal medulla secretes the
specified by the physician." Rationale: The women require 1,500 mg per day. It's often, interphalangeal joint catecholamines — epinephrine and
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norepinephrine. The parathyroids secrete produces three types of hormones: who's HIV positive can give birth to a baby Rationale: The lymphocyte provides adaptive
parathyroid hormone. glucocorticoids, mineralocorticoids, and who's HIV negative. immunity — recognition of a foreign antigen
70. Answer: (C) They debride the wound and androgens. The medulla produces 80. Answer: (C) "Avoid sharing such articles as and formation of memory cells against the
promote healing by secondary intention catecholamines— epinephrine and toothbrushes and razors." antigen. Adaptive immunity is mediated by B
Rationale: For this client, wet-to-dry dressings norepinephrine. Rationale: The human immunodeficiency virus and T lymphocytes and can be acquired
are most appropriate because they clean the 76. Answer: (A) Hypocalcemia (HIV), which causes AIDS, is most actively or passively. The neutrophil is crucial
foot ulcer by debriding exudate and necrotic Rationale: Hypocalcemia may follow thyroid concentrated in the blood. For this reason, the to phagocytosis. The basophil plays an
tissue, thus promoting healing by secondary surgery if the parathyroid glands were client shouldn't share personal articles that important role in the release of inflammatory
intention. Moist, transparent dressings removed accidentally. Signs and symptoms of may be blood-contaminated, such as mediators. The monocyte functions in
contain exudate and provide a moist wound hypocalcemia may be delayed for up to 7 days toothbrushes and razors, with other family phagocytosis and monokine production.
environment. Hydrocolloid dressings prevent after surgery. Thyroid surgery doesn't directly members. HIV isn't transmitted by bathing or 85. Answer: (A) moisture replacement.
the entrance of microorganisms and minimize cause serum sodium, potassium, or by eating from plates, utensils, or serving Rationale: Sjogren's syndrome is an
wound discomfort. Dry sterile dressings magnesium abnormalities. Hyponatremia may dishes used by a person with AIDS. autoimmune disorder leading to progressive
protect the wound from mechanical trauma occur if the client inadvertently received too 81. Answer: (B) Pallor, tachycardia, and a sore loss of lubrication of the skin, GI tract, ears,
and promote healing. much fluid; however, this can happen to any tongue nose, and vagina. Moisture replacement is the
71. Answer: (A) Hyperkalemia surgical client receiving I.V. fluid therapy, not Rationale: Pallor, tachycardia, and a sore mainstay of therapy. Though malnutrition and
Rationale: In adrenal insufficiency, the client just one recovering from thyroid surgery. tongue are all characteristic findings in electrolyte imbalance may occur as a result of
has hyperkalemia due to reduced aldosterone Hyperkalemia and hypermagnesemia usually pernicious anemia. Other clinical Sjogren's syndrome's effect on the GI tract, it
secretion. BUN increases as the glomerular are associated with reduced renal excretion of manifestations include anorexia; weight loss; a isn't the predominant problem. Arrhythmias
filtration rate is reduced. Hyponatremia is potassium and magnesium, not thyroid smooth, beefy red tongue; a wide pulse aren't a problem associated with Sjogren's
caused by reduced aldosterone secretion. surgery. pressure; palpitations; angina; weakness; syndrome.
Reduced cortisol secretion leads to impaired 77. Answer: (D) Carcinoembryonic antigen level fatigue; and paresthesia of the hands and feet. 86. Answer: (C) stool for Clostridium difficile test.
glyconeogenesis and a reduction of glycogen Rationale: In clients who smoke, the level of Bradycardia, reduced pulse pressure, weight Rationale: Immunosuppressed clients — for
in the liver and muscle, causing hypoglycemia. carcinoembryonic antigen is elevated. gain, and double vision aren't characteristic example, clients receiving chemotherapy, —
72. Answer: (C) Restricting fluids Therefore, it can't be used as a general findings in pernicious anemia. are at risk for infection with C. difficile, which
Rationale: To reduce water retention in a indicator of cancer. However, it is helpful in 82. Answer: (B) Administer epinephrine, as causes "horse barn" smelling diarrhea.
client with the SIADH, the nurse should monitoring cancer treatment because the prescribed, and prepare to intubate the client Successful treatment begins with an accurate
restrict fluids. Administering fluids by any level usually falls to normal within 1 month if if necessary. diagnosis, which includes a stool test. The
route would further increase the client's treatment is successful. An elevated acid Rationale: To reverse anaphylactic shock, the ELISA test is diagnostic for human
already heightened fluid load. phosphatase level may indicate prostate nurse first should administer epinephrine, a immunodeficiency virus (HIV) and isn't
73. Answer: (D) glycosylated hemoglobin level. cancer. An elevated alkaline phosphatase level potent bronchodilator as prescribed. The indicated in this case. An electrolyte panel and
Rationale: Because some of the glucose in the may reflect bone metastasis. An elevated physician is likely to order additional hemogram may be useful in the overall
bloodstream attaches to some of the serum calcitonin level usually signals thyroid medications, such as antihistamines and evaluation of a client but aren't diagnostic for
hemoglobin and stays attached during the cancer. corticosteroids; if these medications don't specific causes of diarrhea. A flat plate of the
120-day life span of red blood cells, 78. Answer: (B) Dyspnea, tachycardia, and pallor relieve the respiratory compromise associated abdomen may provide useful information
glycosylated hemoglobin levels provide Rationale: Signs of iron-deficiency anemia with anaphylaxis, the nurse should prepare to about bowel function but isn't indicated in the
information about blood glucose levels during include dyspnea, tachycardia, and pallor as intubate the client. No antidote for penicillin case of "horse barn" smelling diarrhea.
the previous 3 months. Fasting blood glucose well as fatigue, listlessness, irritability, and exists; however, the nurse should continue to 87. Answer: (D) Western blot test with ELISA.
and urine glucose levels only give information headache. Night sweats, weight loss, and monitor the client's vital signs. A client who Rationale: HIV infection is detected by
about glucose levels at the point in time when diarrhea may signal acquired remains hypotensive may need fluid analyzing blood for antibodies to HIV, which
they were obtained. Serum fructosamine immunodeficiency syndrome (AIDS). Nausea, resuscitation and fluid intake and output form approximately 2 to 12 weeks after
levels provide information about blood vomiting, and anorexia may be signs of monitoring; however, administering exposure to HIV and denote infection. The
glucose control over the past 2 to 3 weeks. hepatitis B. Itching, rash, and jaundice may epinephrine is the first priority. Western blot test — electrophoresis of
74. Answer: (C) 4:00 pm result from an allergic or hemolytic reaction. 83. Answer: (D) bilateral hearing loss. antibody proteins — is more than 98%
Rationale: NPH is an intermediate-acting 79. Answer: (D) "I'll need to have a C-section if I Rationale: Prolonged use of aspirin and other accurate in detecting HIV antibodies when
insulin that peaks 8 to 12 hours after become pregnant and have a baby." salicylates sometimes causes bilateral hearing used in conjunction with the ELISA. It isn't
administration. Because the nurse Rationale: The human immunodeficiency virus loss of 30 to 40 decibels. Usually, this adverse specific when used alone. E-rosette
administered NPH insulin at 7 a.m., the client (HIV) is transmitted from mother to child via effect resolves within 2 weeks after the immunofluorescence is used to detect viruses
is at greatest risk for hypoglycemia from 3 the transplacental route, but a Cesarean therapy is discontinued. Aspirin doesn't lead in general; it doesn't confirm HIV infection.
p.m. to 7 p.m. section delivery isn't necessary when the to weight gain or fine motor tremors. Large or Quantification of T-lymphocytes is a useful
75. Answer: (A) Glucocorticoids and androgens mother is HIV-positive. The use of birth toxic salicylate doses may cause respiratory monitoring test but isn't diagnostic for HIV.
Rationale: The adrenal glands have two control will prevent the conception of a child alkalosis, not respiratory acidosis. The ELISA test detects HIV antibody particles
divisions, the cortex and medulla. The cortex who might have HIV. It's true that a mother 84. Answer: (D) Lymphocyte but may yield inaccurate results; a positive
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ELISA result must be confirmed by the temperature in warmer or heating pad; don’t TEST IV - Care of Clients with Physiologic and b. Decrease fluid intake at meal times.
Western blot test. use microwave oven. Psychosocial Alterations c. Avoid foods that in the past caused
88. Answer: (C) Abnormally low hematocrit (HCT) 96. Answer: (C) The client holds the cane with his flatus.
and hemoglobin (Hb) levels left hand, moves the cane forward followed 1. Randy has undergone kidney transplant, what d. Adhere to a bland diet prior to social
Rationale: Low preoperative HCT and Hb by the right leg, and then moves the left leg. assessment would prompt Nurse Katrina to events.
levels indicate the client may require a blood Rationale: The cane acts as a support and aids suspect organ rejection?
transfusion before surgery. If the HCT and Hb in weight bearing for the weaker right leg. a. Sudden weight loss 7. Nurse Ron begins to teach a male client how to
levels decrease during surgery because of 97. Answer: (A) Ask the woman’s family to b. Polyuria perform colostomy irrigations. The nurse would
blood loss, the potential need for a provide personal items such as photos or c. Hypertension evaluate that the instructions were understood
transfusion increases. Possible renal failure is mementos. d. Shock when the client states, “I should:
indicated by elevated BUN or creatinine levels. Rationale: Photos and mementos provide a. Lie on my left side while instilling the
Urine constituents aren't found in the blood. visual stimulation to reduce sensory 2. The immediate objective of nursing care for an irrigating solution.”
Coagulation is determined by the presence of deprivation. overweight, mildly hypertensive male client with b. Keep the irrigating container less than
appropriate clotting factors, not electrolytes. 98. Answer: (B) The client lifts the walker, moves ureteral colic and hematuria is to decrease: 18 inches above the stoma.”
89. Answer: (A) Platelet count, prothrombin time, it forward 10 inches, and then takes several a. Pain c. Instill a minimum of 1200 ml of irrigating
and partial thromboplastin time small steps forward. b. Weight solution to stimulate evacuation of the
Rationale: The diagnosis of DIC is based on the Rationale: A walker needs to be picked up, c. Hematuria bowel.”
results of laboratory studies of prothrombin placed down on all legs. d. Hypertension d. Insert the irrigating catheter deeper into
time, platelet count, thrombin time, partial 99. Answer: (C) Isolation from their families and the stoma if cramping occurs during the
thromboplastin time, and fibrinogen level as familiar surroundings. 3. Matilda, with hyperthyroidism is to receive procedure.”
well as client history and other assessment Rationale: Gradual loss of sight, hearing, and Lugol’s iodine solution before a subtotal
factors. Blood glucose levels, WBC count, taste interferes with normal functioning. thyroidectomy is performed. The nurse is aware 8. Patrick is in the oliguric phase of acute tubular
calcium levels, and potassium levels aren't 100. Answer: (A) Encourage the client to perform that this medication is given to: necrosis and is experiencing fluid and electrolyte
used to confirm a diagnosis of DIC. pursed lip breathing. a. Decrease the total basal metabolic rate. imbalances. The client is somewhat confused
90. Answer: (D) Strawberries Rationale: Purse lip breathing prevents the b. Maintain the function of the parathyroid and complains of nausea and muscle weakness.
Rationale: Common food allergens include collapse of lung unit and helps client control glands. As part of the prescribed therapy to correct this
berries, peanuts, Brazil nuts, cashews, rate and depth of breathing. c. Block the formation of thyroxine by the electrolyte imbalance, the nurse would expect
shellfish, and eggs. Bread, carrots, and thyroid gland. to:
oranges rarely cause allergic reactions. d. Decrease the size and vascularity of the a. Administer Kayexalate
91. Answer: (B) A client with cast on the right leg thyroid gland. b. Restrict foods high in protein
who states, “I have a funny feeling in my right c. Increase oral intake of cheese and milk.
leg.” 4. Ricardo, was diagnosed with type I diabetes. The d. Administer large amounts of normal
Rationale: It may indicate neurovascular nurse is aware that acute hypoglycemia also can saline via I.V.
compromise, requires immediate assessment. develop in the client who is diagnosed with:
92. Answer: (D) A 62-year-old who had an a. Liver disease 9. Mario has burn injury. After Forty48 hours, the
abdominal-perineal resection three days ago; b. Hypertension physician orders for Mario 2 liters of IV fluid to
client complaints of chills. c. Type 2 diabetes be administered q12 h. The drop factor of the
Rationale: The client is at risk for peritonitis; d. Hyperthyroidism tubing is 10 gtt/ml. The nurse should set the
should be assessed for further symptoms and flow to provide:
infection. 5. Tracy is receiving combination chemotherapy for a. 18 gtt/min
93. Answer: (C) The client spontaneously flexes treatment of metastatic carcinoma. Nurse Ruby b. 28 gtt/min
his wrist when the blood pressure is obtained. should monitor the client for the systemic side c. 32 gtt/min
Rationale: Carpal spasms indicate effect of: d. 36 gtt/min
hypocalcemia. a. Ascites
94. Answer: (D) Use comfort measures and b. Nystagmus 10. Terence suffered from burn injury. Using the rule
pillows to position the client. c. Leukopenia of nines, which has the largest percent of burns?
Rationale: Using comfort measures and d. Polycythemia a. Face and neck
pillows to position the client is a non- b. Right upper arm and penis
pharmacological methods of pain relief. 6. Norma, with recent colostomy expresses c. Right thigh and penis
95. Answer: (B) Warm the dialysate solution. concern about the inability to control the d. Upper trunk
Rationale: Cold dialysate increases discomfort. passage of gas. Nurse Oliver should suggest that
The solution should be warmed to body the client plan to: 11. Herbert, a 45 year old construction engineer is
a. Eliminate foods high in cellulose. brought to the hospital unconscious after falling
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from a 2-story building. When assessing the d. Only ice chips and cold liquids will be b. Increased serum levels of potassium, b. Palpate the abdomen.
client, the nurse would be most concerned if the allowed initially. magnesium, and calcium. c. Change the client's position.
assessment revealed: c. Blood urea nitrogen (BUN) 100 mg/dl d. Insert a rectal tube.
a. Reactive pupils 16. Nurse Tristan is caring for a male client in acute and serum creatinine 6.5 mg/ dl.
b. A depressed fontanel renal failure. The nurse should expect hypertonic d. Uric acid analysis 3.5 mg/dl and 24. Wilfredo with a recent history of rectal bleeding
c. Bleeding from ears glucose, insulin infusions, and sodium phenolsulfonphthalein (PSP) excretion is being prepared for a colonoscopy. How should
d. An elevated temperature bicarbonate to be used to treat: 75%. the nurse Patricia position the client for this test
a. hypernatremia. initially?
12. Nurse Sherry is teaching male client regarding b. hypokalemia. 20. Katrina has an abnormal result on a a. Lying on the right side with legs straight
his permanent artificial pacemaker. Which c. hyperkalemia. Papanicolaou test. After admitting that she read b. Lying on the left side with knees bent
information given by the nurse shows her d. hypercalcemia. her chart while the nurse was out of the room, c. Prone with the torso elevated
knowledge deficit about the artificial cardiac Katrina asks what dysplasia means. Which d. Bent over with hands touching the floor
pacemaker? 17. Ms. X has just been diagnosed with condylomata definition should the nurse provide?
a. take the pulse rate once a day, in the acuminata (genital warts). What information is a. Presence of completely undifferentiated 25. A male client with inflammatory bowel disease
morning upon awakening appropriate to tell this client? tumor cells that don't resemble cells of undergoes an ileostomy. On the first day after
b. May be allowed to use electrical a. This condition puts her at a higher risk the tissues of their origin. surgery, Nurse Oliver notes that the client's
appliances for cervical cancer; therefore, she should b. Increase in the number of normal cells in stoma appears dusky. How should the nurse
c. Have regular follow up care have a Papanicolaou (Pap) smear a normal arrangement in a tissue or an interpret this finding?
d. May engage in contact sports annually. organ. a. Blood supply to the stoma has been
b. The most common treatment is c. Replacement of one type of fully interrupted.
13. The nurse is ware that the most relevant metronidazole (Flagyl), which should differentiated cell by another in tissues b. This is a normal finding 1 day after
knowledge about oxygen administration to a eradicate the problem within 7 to 10 where the second type normally isn't surgery.
male client with COPD is days. found. c. The ostomy bag should be adjusted.
a. Oxygen at 1-2L/min is given to maintain c. The potential for transmission to her d. Alteration in the size, shape, and d. An intestinal obstruction has occurred.
the hypoxic stimulus for breathing. sexual partner will be eliminated if organization of differentiated cells.
b. Hypoxia stimulates the central condoms are used every time they have 26. Anthony suffers burns on the legs, which nursing
chemoreceptors in the medulla that sexual intercourse. 21. During a routine checkup, Nurse Mariane intervention helps prevent contractures?
makes the client breath. d. The human papillomavirus (HPV), which assesses a male client with acquired a. Applying knee splints
c. Oxygen is administered best using a non- causes condylomata acuminata, can't be immunodeficiency syndrome (AIDS) for signs and b. Elevating the foot of the bed
rebreathing mask transmitted during oral sex. symptoms of cancer. What is the most common c. Hyperextending the client's palms
d. Blood gases are monitored using a pulse AIDS-related cancer? d. Performing shoulder range-of-motion
oximeter. 18. Maritess was recently diagnosed with a a. Squamous cell carcinoma exercises
genitourinary problem and is being examined in b. Multiple myeloma
14. Tonny has undergoes a left thoracotomy and a the emergency department. When palpating her c. Leukemia 27. Nurse Ron is assessing a client admitted with
partial pneumonectomy. Chest tubes are kidneys, the nurse should keep which anatomical d. Kaposi's sarcoma second- and third-degree burns on the face,
inserted, and one-bottle water-seal drainage is fact in mind? arms, and chest. Which finding indicates a
instituted in the operating room. In the a. The left kidney usually is slightly higher 22. Ricardo is scheduled for a prostatectomy, and potential problem?
postanesthesia care unit Tonny is placed in than the right one. the anesthesiologist plans to use a spinal a. Partial pressure of arterial oxygen
Fowler's position on either his right side or on b. The kidneys are situated just above the (subarachnoid) block during surgery. In the (PaO2) value of 80 mm Hg.
his back. The nurse is aware that this position: adrenal glands. operating room, the nurse positions the client b. Urine output of 20 ml/hour.
a. Reduce incisional pain. c. The average kidney is approximately 5 according to the anesthesiologist's instructions. c. White pulmonary secretions.
b. Facilitate ventilation of the left lung. cm (2") long and 2 to 3 cm (¾" to 1-1/8") Why does the client require special positioning d. Rectal temperature of 100.6° F (38° C).
c. Equalize pressure in the pleural space. wide. for this type of anesthesia?
d. Increase venous return d. The kidneys lie between the 10th and a. To prevent confusion 28. Mr. Mendoza who has suffered a
12th thoracic vertebrae. b. To prevent seizures cerebrovascular accident (CVA) is too weak to
15. Kristine is scheduled for a bronchoscopy. When c. To prevent cerebrospinal fluid (CSF) move on his own. To help the client avoid
teaching Kristine what to expect afterward, the 19. Jestoni with chronic renal failure (CRF) is leakage pressure ulcers, Nurse Celia should:
nurse's highest priority of information would be: admitted to the urology unit. The nurse is aware d. To prevent cardiac arrhythmias a. Turn him frequently.
a. Food and fluids will be withheld for at that the diagnostic test are consistent with CRF if b. Perform passive range-of-motion (ROM)
least 2 hours. the result is: 23. A male client had a nephrectomy 2 days ago and exercises.
b. Warm saline gargles will be done q 2h. a. Increased pH with decreased hydrogen is now complaining of abdominal pressure and c. Reduce the client's fluid intake.
c. Coughing and deep-breathing exercises ions. nausea. The first nursing action should be to: d. Encourage the client to use a footboard.
will be done q2h. a. Auscultate bowel sounds.
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29. Nurse Maria plans to administer dexamethasone 34. A 37-year-old male client was admitted to the c. Electrocardiogram, complete blood 43. The nurse is aware that the following symptom
cream to a female client who has dermatitis over coronary care unit (CCU) 2 days ago with an count, testing for occult blood, is most commonly an early indication of stage 1
the anterior chest. How should the nurse apply acute myocardial infarction. Which of the comprehensive serum metabolic panel. Hodgkin’s disease?
this topical agent? following actions would breach the client d. Electroencephalogram, alkaline a. Pericarditis
a. With a circular motion, to enhance confidentiality? phosphatase and aspartate b. Night sweat
absorption. a. The CCU nurse gives a verbal report to aminotransferase levels, basic serum c. Splenomegaly
b. With an upward motion, to increase the nurse on the telemetry unit before metabolic panel d. Persistent hypothermia
blood supply to the affected area transferring the client to that unit
c. In long, even, outward, and downward b. The CCU nurse notifies the on-call 38. Macario had coronary artery bypass graft (CABG) 44. Francis with leukemia has neutropenia. Which of
strokes in the direction of hair growth physician about a change in the client’s surgery 3 days ago. Which of the following the following functions must frequently
d. In long, even, outward, and upward condition conditions is suspected by the nurse when a assessed?
strokes in the direction opposite hair c. The emergency department nurse calls decrease in platelet count from 230,000 ul to a. Blood pressure
growth up the latest electrocardiogram results 5,000 ul is noted? b. Bowel sounds
to check the client’s progress. a. Pancytopenia c. Heart sounds
30. Nurse Kate is aware that one of the following d. At the client’s request, the CCU nurse b. Idiopathic thrombocytopemic purpura d. Breath sounds
classes of medication protects the ischemic updates the client’s wife on his condition (ITP)
myocardium by blocking catecholamines and c. Disseminated intravascular coagulation 45. The nurse knows that neurologic complications
sympathetic nerve stimulation is: 35. A male client arriving in the emergency (DIC) of multiple myeloma (MM) usually involve which
a. Beta -adrenergic blockers department is receiving cardiopulmonary d. Heparin-associated thrombosis and of the following body system?
b. Calcium channel blocker resuscitation from paramedics who are giving thrombocytopenia (HATT) a. Brain
c. Narcotics ventilations through an endotracheal (ET) tube b. Muscle spasm
d. Nitrates that they placed in the client’s home. During a 39. Which of the following drugs would be ordered c. Renal dysfunction
pause in compressions, the cardiac monitor by the physician to improve the platelet count in d. Myocardial irritability
31. A male client has jugular distention. On what shows narrow QRS complexes and a heart rate a male client with idiopathic thrombocytopenic
position should the nurse place the head of the of beats/minute with a palpable pulse. Which of purpura (ITP)? 46. Nurse Patricia is aware that the average length
bed to obtain the most accurate reading of the following actions should the nurse take first? a. Acetylsalicylic acid (ASA) of time from human immunodeficiency virus
jugular vein distention? a. Start an L.V. line and administer b. Corticosteroids (HIV) infection to the development of acquired
a. High Fowler’s amiodarone (Cardarone), 300 mg L.V. c. Methotrezate immunodeficiency syndrome (AIDS)?
b. Raised 10 degrees over 10 minutes. d. Vitamin K a. Less than 5 years
c. Raised 30 degrees b. Check endotracheal tube placement. b. 5 to 7 years
d. Supine position c. Obtain an arterial blood gas (ABG) 40. A female client is scheduled to receive a heart c. 10 years
sample. valve replacement with a porcine valve. Which d. More than 10 years
32. The nurse is aware that one of the following d. Administer atropine, 1 mg L.V. of the following types of transplant is this?
classes of medications maximizes cardiac a. Allogeneic 47. An 18-year-old male client admitted with heat
performance in clients with heart failure by 36. After cardiac surgery, a client’s blood pressure b. Autologous stroke begins to show signs of disseminated
increasing ventricular contractility? measures 126/80 mm Hg. Nurse Katrina c. Syngeneic intravascular coagulation (DIC). Which of the
a. Beta-adrenergic blockers determines that mean arterial pressure (MAP) is d. Xenogeneic following laboratory findings is most consistent
b. Calcium channel blocker which of the following? with DIC?
c. Diuretics a. 46 mm Hg 41. Marco falls off his bicycle and injuries his ankle. a. Low platelet count
d. Inotropic agents b. 80 mm Hg Which of the following actions shows the initial b. Elevated fibrinogen levels
c. 95 mm Hg response to the injury in the extrinsic pathway? c. Low levels of fibrin degradation products
33. A male client has a reduced serum high-density d. 90 mm Hg a. Release of Calcium d. Reduced prothrombin time
lipoprotein (HDL) level and an elevated low- b. Release of tissue thromboplastin
density lipoprotein (LDL) level. Which of the 37. A female client arrives at the emergency c. Conversion of factors XII to factor XIIa 48. Mario comes to the clinic complaining of fever,
following dietary modifications is not department with chest and stomach pain and a d. Conversion of factor VIII to factor VIIIa drenching night sweats, and unexplained weight
appropriate for this client? report of black tarry stool for several months. 42. Instructions for a client with systemic lupus loss over the past 3 months. Physical
a. Fiber intake of 25 to 30 g daily Which of the following order should the nurse erythematosus (SLE) would include information examination reveals a single enlarged
b. Less than 30% of calories from fat Oliver anticipate? about which of the following blood dyscrasias? supraclavicular lymph node. Which of the
c. Cholesterol intake of less than 300 mg a. Cardiac monitor, oxygen, creatine kinase a. Dressler’s syndrome following is the most probable diagnosis?
daily and lactate dehydrogenase levels b. Polycythemia a. Influenza
d. Less than 10% of calories from saturated b. Prothrombin time, partial c. Essential thrombocytopenia b. Sickle cell anemia
fat thromboplastin time, fibrinogen and d. Von Willebrand’s disease c. Leukemia
fibrin split product values. d. Hodgkin’s disease
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red and swollen, when the IV is touched Stacy decreased RBC count, decreased WBC
49. A male client with a gunshot wound requires an shouts in pain. The first nursing action to take is: Situation: Mr. Gonzales was admitted to the hospital count.
emergency blood transfusion. His blood type is a. Notify the physician with ascites and jaundice. To rule out cirrhosis of the d. Intermitted lower back pain, decreased
AB negative. Which blood type would be the b. Flush the IV line with saline solution liver: blood pressure, decreased RBC count,
safest for him to receive? c. Immediately discontinue the infusion increased WBC count.
a. AB Rh-positive d. Apply an ice pack to the site, followed by 59. Which laboratory test indicates liver cirrhosis?
b. A Rh-positive warm compress. a. Decreased red blood cell count 64. After undergoing a cardiac catheterization, Tracy
c. A Rh-negative b. Decreased serum acid phosphate level has a large puddle of blood under his buttocks.
d. O Rh-positive 54. The term “blue bloater” refers to a male client c. Elevated white blood cell count Which of the following steps should the nurse
which of the following conditions? d. Elevated serum aminotransferase take first?
Situation: Stacy is diagnosed with acute lymphoid a. Adult respiratory distress syndrome a. Call for help.
leukemia (ALL) and beginning chemotherapy. (ARDS) 60. 60.The biopsy of Mr. Gonzales confirms the b. Obtain vital signs
b. Asthma diagnosis of cirrhosis. Mr. Gonzales is at c. Ask the client to “lift up”
50. Stacy is discharged from the hospital following c. Chronic obstructive bronchitis increased risk for excessive bleeding primarily d. Apply gloves and assess the groin site
her chemotherapy treatments. Which statement d. Emphysema because of:
of Stacy’s mother indicated that she understands a. Impaired clotting mechanism 65. Which of the following treatment is a suitable
when she will contact the physician? 55. The term “pink puffer” refers to the female b. Varix formation surgical intervention for a client with unstable
a. “I should contact the physician if Stacy client with which of the following conditions? c. Inadequate nutrition angina?
has difficulty in sleeping”. a. Adult respiratory distress syndrome d. Trauma of invasive procedure a. Cardiac catheterization
b. “I will call my doctor if Stacy has (ARDS) b. Echocardiogram
persistent vomiting and diarrhea”. b. Asthma 61. Mr. Gonzales develops hepatic encephalopathy. c. Nitroglycerin
c. “My physician should be called if Stacy is c. Chronic obstructive bronchitis Which clinical manifestation is most common d. Percutaneous transluminal coronary
irritable and unhappy”. d. Emphysema with this condition? angioplasty (PTCA)
d. “Should Stacy have continued hair loss, I a. Increased urine output
need to call the doctor”. 56. Jose is in danger of respiratory arrest following b. Altered level of consciousness 66. The nurse is aware that the following terms used
the administration of a narcotic analgesic. An c. Decreased tendon reflex to describe reduced cardiac output and
51. Stacy’s mother states to the nurse that it is hard arterial blood gas value is obtained. Nurse Oliver d. Hypotension perfusion impairment due to ineffective
to see Stacy with no hair. The best response for would expect the paco2 to be which of the pumping of the heart is:
the nurse is: following values? 62. When Mr. Gonzales regained consciousness, the a. Anaphylactic shock
a. “Stacy looks very nice wearing a hat”. a. 15 mm Hg physician orders 50 ml of Lactose p.o. every 2 b. Cardiogenic shock
b. “You should not worry about her hair, b. 30 mm Hg hours. Mr. Gozales develops diarrhea. The nurse c. Distributive shock
just be glad that she is alive”. c. 40 mm Hg best action would be: d. Myocardial infarction (MI)
c. “Yes it is upsetting. But try to cover up d. 80 mm Hg a. “I’ll see if your physician is in the
your feelings when you are with her or hospital”. 67. A client with hypertension asks the nurse which
else she may be upset”. 57. Timothy’s arterial blood gas (ABG) results are as b. “Maybe you’re reacting to the drug; I factors can cause blood pressure to drop to
d. “This is only temporary; Stacy will re- follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm will withhold the next dose”. normal levels?
grow new hair in 3-6 months, but may Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result c. “I’ll lower the dosage as ordered so the a. Kidneys’ excretion to sodium only.
be different in texture”. represents which of the following conditions? drug causes only 2 to 4 stools a day”. b. Kidneys’ retention of sodium and water
a. Metabolic acidosis d. “Frequently, bowel movements are c. Kidneys’ excretion of sodium and water
52. Stacy has beginning stomatitis. To promote oral b. Metabolic alkalosis needed to reduce sodium level”. d. Kidneys’ retention of sodium and
hygiene and comfort, the nurse in-charge c. Respiratory acidosis excretion of water
should: d. Respiratory alkalosis 63. Which of the following groups of symptoms
a. Provide frequent mouthwash with indicates a ruptured abdominal aortic 68. Nurse Rose is aware that the statement that
normal saline. 58. Norma has started a new drug for hypertension. aneurysm? best explains why furosemide (Lasix) is
b. Apply viscous Lidocaine to oral ulcers as Thirty minutes after she takes the drug, she a. Lower back pain, increased blood administered to treat hypertension is:
needed. develops chest tightness and becomes short of pressure, decreased red blood cell (RBC) a. It dilates peripheral blood vessels.
c. Use lemon glycerine swabs every 2 breath and tachypneic. She has a decreased level count, increased white blood (WBC) b. It decreases sympathetic
hours. of consciousness. These signs indicate which of count. cardioacceleration.
d. Rinse mouth with Hydrogen Peroxide. the following conditions? b. Severe lower back pain, decreased blood c. It inhibits the angiotensin-coverting
a. Asthma attack pressure, decreased RBC count, enzymes
53. During the administration of chemotherapy b. Pulmonary embolism increased WBC count. d. It inhibits reabsorption of sodium and
agents, Nurse Oliver observed that the IV site is c. Respiratory failure c. Severe lower back pain, decreased blood water in the loop of Henle.
d. Rheumatoid arthritis pressure, decreased RBC count,
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69. Nurse Nikki knows that laboratory results 73. JP has been diagnosed with gout and wants to 78. Jomari is diagnosed with hyperosmolar d. Low corticotropin and low cortisol levels
supports the diagnosis of systemic lupus know why colchicine is used in the treatment of hyperglycemic nonketotic syndrome (HHNS) is
erythematosus (SLE) is: gout. Which of the following actions of stabilized and prepared for discharge. When 82. A male client is scheduled for a transsphenoidal
a. Elavated serum complement level colchicines explains why it’s effective for gout? preparing the client for discharge and home hypophysectomy to remove a pituitary tumor.
b. Thrombocytosis, elevated sedimentation a. Replaces estrogen management, which of the following statements Preoperatively, the nurse should assess for
rate b. Decreases infection indicates that the client understands her potential complications by doing which of the
c. Pancytopenia, elevated antinuclear c. Decreases inflammation condition and how to control it? following?
antibody (ANA) titer d. Decreases bone demineralization a. "I can avoid getting sick by not becoming a. Testing for ketones in the urine
d. Leukocysis, elevated blood urea nitrogen dehydrated and by paying attention to b. Testing urine specific gravity
(BUN) and creatinine levels 74. Norma asks for information about osteoarthritis. my need to urinate, drink, or eat more c. Checking temperature every 4 hours
Which of the following statements about than usual." d. Performing capillary glucose testing
70. Arnold, a 19-year-old client with a mild osteoarthritis is correct? b. "If I experience trembling, weakness, every 4 hours
concussion is discharged from the emergency a. Osteoarthritis is rarely debilitating and headache, I should drink a glass of
department. Before discharge, he complains of a b. Osteoarthritis is a rare form of arthritis soda that contains sugar." 83. Capillary glucose monitoring is being performed
headache. When offered acetaminophen, his c. Osteoarthritis is the most common form c. "I will have to monitor my blood glucose every 4 hours for a client diagnosed with
mother tells the nurse the headache is severe of arthritis level closely and notify the physician if diabetic ketoacidosis. Insulin is administered
and she would like her son to have something d. Osteoarthritis afflicts people over 60 it's constantly elevated." using a scale of regular insulin according to
stronger. Which of the following responses by d. "If I begin to feel especially hungry and glucose results. At 2 p.m., the client has a
the nurse is appropriate? 75. Ruby is receiving thyroid replacement therapy thirsty, I'll eat a snack high in capillary glucose level of 250 mg/dl for which he
a. “Your son had a mild concussion, develops the flu and forgets to take her thyroid carbohydrates." receives 8 U of regular insulin. Nurse Mariner
acetaminophen is strong enough.” replacement medicine. The nurse understands should expect the dose's:
b. “Aspirin is avoided because of the that skipping this medication will put the client 79. A 66-year-old client has been complaining of a. onset to be at 2 p.m. and its peak to be
danger of Reye’s syndrome in children or at risk for developing which of the following life- sleeping more, increased urination, anorexia, at 3 p.m.
young adults.” threatening complications? weakness, irritability, depression, and bone pain b. onset to be at 2:15 p.m. and its peak to
c. “Narcotics are avoided after a head a. Exophthalmos that interferes with her going outdoors. Based be at 3 p.m.
injury because they may hide a b. Thyroid storm on these assessment findings, the nurse would c. onset to be at 2:30 p.m. and its peak to
worsening condition.” c. Myxedema coma suspect which of the following disorders? be at 4 p.m.
d. Stronger medications may lead to d. Tibial myxedema a. Diabetes mellitus d. onset to be at 4 p.m. and its peak to be
vomiting, which increases the b. Diabetes insipidus at 6 p.m.
intracarnial pressure (ICP).” 76. Nurse Sugar is assessing a client with Cushing's c. Hypoparathyroidism
71. When evaluating an arterial blood gas from a syndrome. Which observation should the nurse d. Hyperparathyroidism 84. The physician orders laboratory tests to confirm
male client with a subdural hematoma, the report to the physician immediately? hyperthyroidism in a female client with classic
nurse notes the Paco2 is 30 mm Hg. Which of a. Pitting edema of the legs 80. Nurse Lourdes is teaching a client recovering signs and symptoms of this disorder. Which test
the following responses best describes the b. An irregular apical pulse from addisonian crisis about the need to take result would confirm the diagnosis?
result? c. Dry mucous membranes fludrocortisone acetate and hydrocortisone at a. No increase in the thyroid-stimulating
a. Appropriate; lowering carbon dioxide d. Frequent urination home. Which statement by the client indicates hormone (TSH) level after 30 minutes
(CO2) reduces intracranial pressure (ICP) an understanding of the instructions? during the TSH stimulation test
b. Emergent; the client is poorly 77. Cyrill with severe head trauma sustained in a car a. "I'll take my hydrocortisone in the late b. A decreased TSH level
oxygenated accident is admitted to the intensive care unit. afternoon, before dinner." c. An increase in the TSH level after 30
c. Normal Thirty-six hours later, the client's urine output b. "I'll take all of my hydrocortisone in the minutes during the TSH stimulation test
d. Significant; the client has alveolar suddenly rises above 200 ml/hour, leading the morning, right after I wake up." d. Below-normal levels of serum
hypoventilation nurse to suspect diabetes insipidus. Which c. "I'll take two-thirds of the dose when I triiodothyronine (T3) and serum
laboratory findings support the nurse's suspicion wake up and one-third in the late thyroxine (T4) as detected by
72. When prioritizing care, which of the following of diabetes insipidus? afternoon." radioimmunoassay
clients should the nurse Olivia assess first? a. Above-normal urine and serum d. "I'll take the entire dose at bedtime."
a. A 17-year-old client’s 24-hours osmolality levels 85. Rico with diabetes mellitus must learn how to
postappendectomy b. Below-normal urine and serum 81. Which of the following laboratory test results self-administer insulin. The physician has
b. A 33-year-old client with a recent osmolality levels would suggest to the nurse Len that a client has prescribed 10 U of U-100 regular insulin and 35
diagnosis of Guillain-Barre syndrome c. Above-normal urine osmolality level, a corticotropin-secreting pituitary adenoma? U of U-100 isophane insulin suspension (NPH) to
c. A 50-year-old client 3 days below-normal serum osmolality level a. High corticotropin and low cortisol levels be taken before breakfast. When teaching the
postmyocardial infarction d. Below-normal urine osmolality level, b. Low corticotropin and high cortisol levels client how to select and rotate insulin injection
d. A 50-year-old client with diverticulitis above-normal serum osmolality level c. High corticotropin and high cortisol sites, the nurse should provide which
levels instruction?
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a. "Inject insulin into healthy tissue with a. Adult respiratory distress syndrome c. “Every four hours I should remove the
large blood vessels and nerves." (ARDS) 96. Aldo with a massive pulmonary embolism will stockings for a half hour.”
b. "Rotate injection sites within the same b. Atelectasis have an arterial blood gas analysis performed to d. “I should put on the stockings before
anatomic region, not among different c. Bronchitis determine the extent of hypoxia. The acid-base getting out of bed in the morning.”
regions." d. Pneumonia disorder that may be present is?
c. "Administer insulin into areas of scar a. Metabolic acidosis
tissue or hypotrophy whenever 91. A 67-year-old client develops acute shortness of b. Metabolic alkalosis
possible." breath and progressive hypoxia requiring right c. Respiratory acidosis
d. "Administer insulin into sites above femur. The hypoxia was probably caused by d. Respiratory alkalosis
muscles that you plan to exercise heavily which of the following conditions?
later that day." a. Asthma attack 97. After a motor vehicle accident, Armand an 22-
b. Atelectasis year-old client is admitted with a pneumothorax.
86. Nurse Sarah expects to note an elevated serum c. Bronchitis The surgeon inserts a chest tube and attaches it
glucose level in a client with hyperosmolar d. Fat embolism to a chest drainage system. Bubbling soon
hyperglycemic nonketotic syndrome (HHNS). appears in the water seal chamber. Which of the
Which other laboratory finding should the nurse 92. A client with shortness of breath has decreased following is the most likely cause of the
anticipate? to absent breath sounds on the right side, from bubbling?
a. Elevated serum acetone level the apex to the base. Which of the following a. Air leak
b. Serum ketone bodies conditions would best explain this? b. Adequate suction
c. Serum alkalosis a. Acute asthma c. Inadequate suction
d. Below-normal serum potassium level b. Chronic bronchitis d. Kinked chest tube
c. Pneumonia
87. For a client with Graves' disease, which nursing d. Spontaneous pneumothorax 98. Nurse Michelle calculates the IV flow rate for a
intervention promotes comfort? postoperative client. The client receives 3,000 ml
a. Restricting intake of oral fluids 93. A 62-year-old male client was in a motor vehicle of Ringer’s lactate solution IV to run over 24
b. Placing extra blankets on the client's bed accident as an unrestrained driver. He’s now in hours. The IV infusion set has a drop factor of 10
c. Limiting intake of high-carbohydrate the emergency department complaining of drops per milliliter. The nurse should regulate
foods difficulty of breathing and chest pain. On the client’s IV to deliver how many drops per
d. Maintaining room temperature in the auscultation of his lung field, no breath sounds minute?
low-normal range are present in the upper lobe. This client may a. 18
have which of the following conditions? b. 21
88. Patrick is treated in the emergency department a. Bronchitis c. 35
for a Colles' fracture sustained during a fall. b. Pneumonia d. 40
What is a Colles' fracture? c. Pneumothorax
a. Fracture of the distal radius d. Tuberculosis (TB) 99. Mickey, a 6-year-old child with a congenital
b. Fracture of the olecranon heart disorder is admitted with congestive heart
c. Fracture of the humerus 94. If a client requires a pneumonectomy, what fills failure. Digoxin (lanoxin) 0.12 mg is ordered for
d. Fracture of the carpal scaphoid the area of the thoracic cavity? the child. The bottle of Lanoxin contains .05 mg
a. The space remains filled with air only of Lanoxin in 1 ml of solution. What amount
89. Cleo is diagnosed with osteoporosis. Which b. The surgeon fills the space with a gel should the nurse administer to the child?
electrolytes are involved in the development of c. Serous fluids fills the space and a. 1.2 ml
this disorder? consolidates the region b. 2.4 ml
a. Calcium and sodium d. The tissue from the other lung grows c. 3.5 ml
b. Calcium and phosphorous over to the other side d. 4.2 ml
c. Phosphorous and potassium
d. Potassium and sodium 95. Hemoptysis may be present in the client with a 100. Nurse Alexandra teaches a client about elastic
pulmonary embolism because of which of the stockings. Which of the following statements,
90. Johnny a firefighter was involved in following reasons? if made by the client, indicates to the nurse
extinguishing a house fire and is being treated to a. Alveolar damage in the infracted area that the teaching was successful?
smoke inhalation. He develops severe hypoxia b. Involvement of major blood vessels in a. “I will wear the stockings until the
48 hours after the incident, requiring intubation the occluded area physician tells me to remove them.”
and mechanical ventilation. He most likely has c. Loss of lung parenchyma b. “I should wear the stockings even when I
developed which of the following conditions? d. Loss of lung tissue am sleep.”
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Answers and Rationale – Care of Clients with 10. Answer: (D) Upper trunk Rationale: Hyperkalemia is a common increases serum levels of potassium,
Physiologic and Psychosocial Alterations Rationale: The percentage designated for complication of acute renal failure. It's magnesium, and phosphorous, and
each burned part of the body using the life-threatening if immediate action isn't decreases serum levels of calcium. A uric
1. Answer: (C) Hypertension rule of nines: Head and neck 9%; Right taken to reverse it. The administration of acid analysis of 3.5 mg/dl falls within the
Rationale: Hypertension, along with fever, upper extremity 9%; Left upper extremity glucose and regular insulin, with sodium normal range of 2.7 to 7.7 mg/dl; PSP
and tenderness over the grafted kidney, 9%; Anterior trunk 18%; Posterior trunk bicarbonate if necessary, can temporarily excretion of 75% also falls with the normal
reflects acute rejection. 18%; Right lower extremity 18%; Left prevent cardiac arrest by moving range of 60% to 75%.
2. Answer: (A) Pain lower extremity 18%; Perineum 1%. potassium into the cells and temporarily 20. Answer: (D) Alteration in the size, shape,
Rationale: Sharp, severe pain (renal colic) 11. Answer: (C) Bleeding from ears reducing serum potassium levels. and organization of differentiated cells
radiating toward the genitalia and thigh is Rationale: The nurse needs to perform a Hypernatremia, hypokalemia, and Rationale: Dysplasia refers to an alteration
caused by uretheral distention and thorough assessment that could indicate hypercalcemia don't usually occur with in the size, shape, and organization of
smooth muscle spasm; relief form pain is alterations in cerebral function, increased acute renal failure and aren't treated with differentiated cells. The presence of
the priority. intracranial pressures, fractures and glucose, insulin, or sodium bicarbonate. completely undifferentiated tumor cells
3. Answer: (D) Decrease the size and bleeding. Bleeding from the ears occurs 17. Answer: (A) This condition puts her at a that don't resemble cells of the tissues of
vascularity of the thyroid gland. only with basal skull fractures that can higher risk for cervical cancer; therefore, their origin is called anaplasia. An increase
Rationale: Lugol’s solution provides easily contribute to increased intracranial she should have a Papanicolaou (Pap) in the number of normal cells in a normal
iodine, which aids in decreasing the pressure and brain herniation. smear annually. arrangement in a tissue or an organ is
vascularity of the thyroid gland, which 12. Answer: (D) may engage in contact sports Rationale: Women with condylomata called hyperplasia. Replacement of one
limits the risk of hemorrhage when Rationale: The client should be advised by acuminata are at risk for cancer of the type of fully differentiated cell by another
surgery is performed. the nurse to avoid contact sports. This will cervix and vulva. Yearly Pap smears are in tissues where the second type normally
4. Answer: (A) Liver Disease prevent trauma to the area of the very important for early detection. isn't found is called metaplasia.
Rationale: The client with liver disease has pacemaker generator. Because condylomata acuminata is a 21. Answer: (D) Kaposi's sarcoma
a decreased ability to metabolize 13. Answer: (A) Oxygen at 1-2L/min is given to virus, there is no permanent cure. Rationale: Kaposi's sarcoma is the most
carbohydrates because of a decreased maintain the hypoxic stimulus for Because condylomata acuminata can common cancer associated with AIDS.
ability to form glycogen (glycogenesis) and breathing. occur on the vulva, a condom won't Squamous cell carcinoma, multiple
to form glucose from glycogen. Rationale: COPD causes a chronic CO2 protect sexual partners. HPV can be myeloma, and leukemia may occur in
5. Answer: (C) Leukopenia retention that renders the medulla transmitted to other parts of the body, anyone and aren't associated specifically
Rationale: Leukopenia, a reduction in insensitive to the CO2 stimulation for such as the mouth, oropharynx, and with AIDS.
WBCs, is a systemic effect of breathing. The hypoxic state of the client larynx. 22. Answer: (C) To prevent cerebrospinal fluid
chemotherapy as a result of then becomes the stimulus for breathing. 18. Answer: (A) The left kidney usually is (CSF) leakage
myelosuppression. Giving the client oxygen in low slightly higher than the right one. Rationale: The client receiving a
6. Answer: (C) Avoid foods that in the past concentrations will maintain the client’s Rationale: The left kidney usually is subarachnoid block requires special
caused flatus. hypoxic drive. slightly higher than the right one. An positioning to prevent CSF leakage and
Rationale: Foods that bothered a person 14. Answer: (B) Facilitate ventilation of the adrenal gland lies atop each kidney. The headache and to ensure proper anesthetic
preoperatively will continue to do so after left lung. average kidney measures approximately distribution. Proper positioning doesn't
a colostomy. Rationale: Since only a partial 11 cm (4-3/8") long, 5 to 5.8 cm (2" to help prevent confusion, seizures, or
7. Answer: (B) Keep the irrigating container pneumonectomy is done, there is a need 2¼") wide, and 2.5 cm (1") thick. The cardiac arrhythmias.
less than 18 inches above the stoma.” to promote expansion of this remaining kidneys are located retroperitoneally, in 23. Answer: (A) Auscultate bowel sounds.
Rationale: This height permits the solution Left lung by positioning the client on the the posterior aspect of the abdomen, on Rationale: If abdominal distention is
to flow slowly with little force so that opposite unoperated side. either side of the vertebral column. They accompanied by nausea, the nurse must
excessive peristalsis is not immediately 15. Answer: (A) Food and fluids will be lie between the 12th thoracic and 3rd first auscultate bowel sounds. If bowel
precipitated. withheld for at least 2 hours. lumbar vertebrae. sounds are absent, the nurse should
8. Answer: (A) Administer Kayexalate Rationale: Prior to bronchoscopy, the 19. Answer: (C) Blood urea nitrogen (BUN) suspect gastric or small intestine dilation
Rationale: Kayexalate,a potassium doctors sprays the back of the throat with 100 mg/dl and serum creatinine 6.5mg/dl. and these findings must be reported to
exchange resin, permits sodium to be anesthetic to minimize the gag reflex and Rationale: The normal BUN level ranges 8 the physician. Palpation should be
exchanged for potassium in the intestine, thus facilitate the insertion of the to 23 mg/dl; the normal serum creatinine avoided postoperatively with abdominal
reducing the serum potassium level. bronchoscope. Giving the client food and level ranges from 0.7 to 1.5 mg/dl. The distention. If peristalsis is absent,
9. Answer:(B) 28 gtt/min drink after the procedure without test results in option C are abnormally changing positions and inserting a rectal
Rationale: This is the correct flow rate; checking on the return of the gag reflex elevated, reflecting CRF and the kidneys' tube won't relieve the client's discomfort.
multiply the amount to be infused (2000 can cause the client to aspirate. The gag decreased ability to remove nonprotein 24. Answer: (B) Lying on the left side with
ml) by the drop factor (10) and divide the reflex usually returns after two hours. nitrogen waste from the blood. CRF knees bent
result by the amount of time in minutes 16. Answer: (C) hyperkalemia. causes decreased pH and increased Rationale: For a colonoscopy, the nurse
(12 hours x 60 minutes) hydrogen ions — not vice versa. CRF also initially should position the client on the
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left side with knees bent. Placing the capillaries become occluded, reducing high Fowler’s position, the veins would be ventricular fibrillation and atrial flutter –
client on the right side with legs straight, circulation and oxygenation of the tissues barely discernible above the clavicle. not symptomatic bradycardia.
prone with the torso elevated, or bent and resulting in cell death and ulcer 32. Answer: (D) Inotropic agents 36. Answer: (C) 95 mm Hg
over with hands touching the floor formation. During passive ROM exercises, Rationale: Inotropic agents are Rationale: Use the following formula to
wouldn't allow proper visualization of the the nurse moves each joint through its administered to increase the force of the calculate MAP
large intestine. range of movement, which improves joint heart’s contractions, thereby increasing MAP = systolic + 2 (diastolic)
25. Answer: (A) Blood supply to the stoma has mobility and circulation to the affected ventricular contractility and ultimately 3
been interrupted area but doesn't prevent pressure ulcers. increasing cardiac output. Beta-adrenergic MAP=126 mm Hg + 2 (80 mm Hg)
Rationale: An ileostomy stoma forms as Adequate hydration is necessary to blockers and calcium channel blockers 3
the ileum is brought through the maintain healthy skin and ensure tissue decrease the heart rate and ultimately MAP=286 mm HG
abdominal wall to the surface skin, repair. A footboard prevents plantar decreased the workload of the heart. 3
creating an artificial opening for waste flexion and footdrop by maintaining the Diuretics are administered to decrease the MAP=95 mm Hg
elimination. The stoma should appear foot in a dorsiflexed position. overall vascular volume, also decreasing 37. Answer: (C) Electrocardiogram, complete
cherry red, indicating adequate arterial 29. Answer: (C) In long, even, outward, and the workload of the heart. blood count, testing for occult blood,
perfusion. A dusky stoma suggests downward strokes in the direction of hair 33. Answer: (B) Less than 30% of calories from comprehensive serum metabolic panel.
decreased perfusion, which may result growth fat Rationale: An electrocardiogram evaluates
from interruption of the stoma's blood Rationale: When applying a topical agent, Rationale: A client with low serum HDL the complaints of chest pain, laboratory
supply and may lead to tissue damage or the nurse should begin at the midline and and high serum LDL levels should get less tests determines anemia, and the stool
necrosis. A dusky stoma isn't a normal use long, even, outward, and downward than 30% of daily calories from fat. The test for occult blood determines blood in
finding. Adjusting the ostomy bag strokes in the direction of hair growth. other modifications are appropriate for the stool. Cardiac monitoring, oxygen, and
wouldn't affect stoma color, which This application pattern reduces the risk this client. creatine kinase and lactate
depends on blood supply to the area. An of follicle irritation and skin inflammation. 34. Answer: (C) The emergency department dehydrogenase levels are appropriate for
intestinal obstruction also wouldn't 30. Answer: (A) Beta -adrenergic blockers nurse calls up the latest electrocardiogram a cardiac primary problem. A basic
change stoma color. Rationale: Beta-adrenergic blockers work results to check the client’s progress metabolic panel and alkaline phosphatase
26. Answer: (A) Applying knee splints by blocking beta receptors in the Rationale: The emergency department and aspartate aminotransferase levels
Rationale: Applying knee splints prevents myocardium, reducing the response to nurse is no longer directly involved with assess liver function. Prothrombin time,
leg contractures by holding the joints in a catecholamines and sympathetic nerve the client’s care and thus has no legal partial thromboplastin time, fibrinogen
position of function. Elevating the foot of stimulation. They protect the right to information about his present and fibrin split products are measured to
the bed can't prevent contractures myocardium, helping to reduce the risk of condition. Anyone directly involved in his verify bleeding dyscrasias; an
because this action doesn't hold the joints another infraction by decreasing care (such as the telemetry nurse and the electroencephalogram evaluates brain
in a position of function. Hyperextending a myocardial oxygen demand. Calcium on-call physician) has the right to electrical activity.
body part for an extended time is channel blockers reduce the workload of information about his condition. Because 38. Answer: (D) Heparin-associated
inappropriate because it can cause the heart by decreasing the heart rate. the client requested that the nurse update thrombosis and thrombocytopenia (HATT)
contractures. Performing shoulder range- Narcotics reduce myocardial oxygen his wife on his condition, doing so doesn’t Rationale: HATT may occur after CABG
of-motion exercises can prevent demand, promote vasodilation, and breach confidentiality. surgery due to heparin use during surgery.
contractures in the shoulders, but not in decrease anxiety. Nitrates reduce 35. Answer: (B) Check endotracheal tube Although DIC and ITP cause platelet
the legs. myocardial oxygen consumption bt placement. aggregation and bleeding, neither is
27. Answer: (B) Urine output of 20 ml/hour. decreasing left ventricular end diastolic Rationale: ET tube placement should be common in a client after revascularization
Rationale: A urine output of less than 40 pressure (preload) and systemic vascular confirmed as soon as the client arrives in surgery. Pancytopenia is a reduction in all
ml/hour in a client with burns indicates a resistance (afterload). the emergency department. Once the blood cells.
fluid volume deficit. This client's PaO2 31. Answer: (C) Raised 30 degrees airways is secured, oxygenation and 39. Answer: (B) Corticosteroids
value falls within the normal range (80 to Rationale: Jugular venous pressure is ventilation should be confirmed using an Rationale: Corticosteroid therapy can
100 mm Hg). White pulmonary secretions measured with a centimeter ruler to end-tidal carbon dioxide monitor and decrease antibody production and
also are normal. The client's rectal obtain the vertical distance between the pulse oximetry. Next, the nurse should phagocytosis of the antibody-coated
temperature isn't significantly elevated sternal angle and the point of highest make sure L.V. access is established. If the platelets, retaining more functioning
and probably results from the fluid pulsation with the head of the bed client experiences symptomatic platelets. Methotrexate can cause
volume deficit. inclined between 15 to 30 degrees. bradycardia, atropine is administered as thrombocytopenia. Vitamin K is used to
28. Answer: (A) Turn him frequently. Increased pressure can’t be seen when ordered 0.5 to 1 mg every 3 to 5 minutes treat an excessive anticoagulate state
Rationale: The most important the client is supine or when the head of to a total of 3 mg. Then the nurse should from warfarin overload, and ASA
intervention to prevent pressure ulcers is the bed is raised 10 degrees because the try to find the cause of the client’s arrest decreases platelet aggregation.
frequent position changes, which relieve point that marks the pressure level is by obtaining an ABG sample. Amiodarone 40. Answer: (D) Xenogeneic
pressure on the skin and underlying above the jaw (therefore, not visible). In is indicated for ventricular tachycardia, Rationale: An xenogeneic transplant is
tissues. If pressure isn't relieved, between is between human and another
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species. A syngeneic transplant is between options, which reflect parts of the nervous Rationale: This is the appropriate chronic obstructive bronchitis are bloated
identical twins, allogeneic transplant is system, aren’t usually affected by MM. response. The nurse should help the and cyanotic in appearance.
between two humans, and autologous is a 46. Answer: (C) 10 years mother how to cope with her own feelings 56. Answer: D 80 mm Hg
transplant from the same individual. Rationale: Epidermiologic studies show regarding the child’s disease so as not to Rationale: A client about to go into
41. Answer: (B) the average time from initial contact with affect the child negatively. When the hair respiratory arrest will have inefficient
Rationale: Tissue thromboplastin is HIV to the development of AIDS is 10 grows back, it is still of the same color and ventilation and will be retaining carbon
released when damaged tissue comes in years. texture. dioxide. The value expected would be
contact with clotting factors. Calcium is 47. Answer: (A) Low platelet count 52. Answer: (B) Apply viscous Lidocaine to around 80 mm Hg. All other values are
released to assist the conversion of Rationale: In DIC, platelets and clotting oral ulcers as needed. lower than expected.
factors X to Xa. Conversion of factors XII to factors are consumed, resulting in Rationale: Stomatitis can cause pain and 57. Answer: (C) Respiratory acidosis
XIIa and VIII to IIIa are part of the intrinsic microthrombi and excessive bleeding. As this can be relieved by applying topical Rationale: Because Paco2 is high at 80 mm
pathway. clots form, fibrinogen levels decrease and anesthetics such as lidocaine before Hg and the metabolic measure, HCO3- is
42. Answer: (C) Essential thrombocytopenia the prothrombin time increases. Fibrin mouth care. When the patient is already normal, the client has respiratory acidosis.
Rationale: Essential thrombocytopenia is degeneration products increase as comfortable, the nurse can proceed with The pH is less than 7.35, academic, which
linked to immunologic disorders, such as fibrinolysis takes places. providing the patient with oral rinses of eliminates metabolic and respiratory
SLE and human immunodeficiency virus. 48. Answer: (D) Hodgkin’s disease saline solution mixed with equal part of alkalosis as possibilities. If the HCO3- was
The disorder known as von Willebrand’s Rationale: Hodgkin’s disease typically water or hydrogen peroxide mixed water below 22 mEq/L the client would have
disease is a type of hemophilia and isn’t causes fever night sweats, weight loss, in 1:3 concentrations to promote oral metabolic acidosis.
linked to SLE. Moderate to severe anemia and lymph mode enlargement. Influenza hygiene. Every 2-4 hours. 58. Answer: (C) Respiratory failure
is associated with SLE, not polycythemia. doesn’t last for months. Clients with sickle 53. Answer: (C) Immediately discontinue the Rationale: The client was reacting to the
Dressler’s syndrome is pericarditis that cell anemia manifest signs and symptoms infusion drug with respiratory signs of impending
occurs after a myocardial infarction and of chronic anemia with pallor of the Rationale: Edema or swelling at the IV site anaphylaxis, which could lead to
isn’t linked to SLE. mucous membrane, fatigue, and is a sign that the needle has been eventually respiratory failure. Although
43. Answer: (B) Night sweat decreased tolerance for exercise; they dislodged and the IV solution is leaking the signs are also related to an asthma
Rationale: In stage 1, symptoms include a don’t show fever, night sweats, weight into the tissues causing the edema. The attack or a pulmonary embolism, consider
single enlarged lymph node (usually), loss or lymph node enlargement. patient feels pain as the nerves are the new drug first. Rheumatoid arthritis
unexplained fever, night sweats, malaise, Leukemia doesn’t cause lymph node irritated by pressure and the IV solution. doesn’t manifest these signs.
and generalized pruritis. Although enlargement. The first action of the nurse would be to 59. Answer: (D) Elevated serum
splenomegaly may be present in some 49. Answer: (C) A Rh-negative discontinue the infusion right away to aminotransferase
clients, night sweats are generally more Rationale: Human blood can sometimes prevent further edema and other Rationale: Hepatic cell death causes
prevalent. Pericarditis isn’t associated contain an inherited D antigen. Persons complication. release of liver enzymes alanine
with Hodgkin’s disease, nor is with the D antigen have Rh-positive blood 54. Answer: (C) Chronic obstructive bronchitis aminotransferase (ALT), aspartate
hypothermia. Moreover, splenomegaly type; those lacking the antigen have Rh- Rationale: Clients with chronic obstructive aminotransferase (AST) and lactate
and pericarditis aren’t symptoms. negative blood. It’s important that a bronchitis appear bloated; they have large dehydrogenase (LDH) into the circulation.
Persistent hypothermia is associated with person with Rh- negative blood receives barrel chest and peripheral edema, Liver cirrhosis is a chronic and irreversible
Hodgkin’s but isn’t an early sign of the Rh-negative blood. If Rh-positive blood is cyanotic nail beds, and at times, disease of the liver characterized by
disease. administered to an Rh-negative person, circumoral cyanosis. Clients with ARDS are generalized inflammation and fibrosis of
44. Answer: (D) Breath sounds the recipient develops anti-Rh agglutinins, acutely short of breath and frequently the liver tissues.
Rationale: Pneumonia, both viral and and sub sequent transfusions with Rh- need intubation for mechanical ventilation 60. Answer: (A) Impaired clotting mechanism
fungal, is a common cause of death in positive blood may cause serious and large amount of oxygen. Clients with Rationale: Cirrhosis of the liver results in
clients with neutropenia, so frequent reactions with clumping and hemolysis of asthma don’t exhibit characteristics of decreased Vitamin K absorption and
assessment of respiratory rate and breath red blood cells. chronic disease, and clients with formation of clotting factors resulting in
sounds is required. Although assessing 50. Answer: (B) “I will call my doctor if Stacy emphysema appear pink and cachectic. impaired clotting mechanism.
blood pressure, bowel sounds, and heart has persistent vomiting and diarrhea”. 55. Answer: (D) Emphysema 61. Answer: (B) Altered level of consciousness
sounds is important, it won’t help detect Rationale: Persistent (more than 24 hours) Rationale: Because of the large amount of Rationale: Changes in behavior and level
pneumonia. vomiting, anorexia, and diarrhea are signs energy it takes to breathe, clients with of consciousness are the first sins of
45. Answer: (B) Muscle spasm of toxicity and the patient should stop the emphysema are usually cachectic. They’re hepatic encephalopathy. Hepatic
Rationale: Back pain or paresthesia in the medication and notify the health care pink and usually breathe through pursed encephalopathy is caused by liver failure
lower extremities may indicate impending provider. The other manifestations are lips, hence the term “puffer.” Clients with and develops when the liver is unable to
spinal cord compression from a spinal expected side effects of chemotherapy. ARDS are usually acutely short of breath. convert protein metabolic product
tumor. This should be recognized and 51. Answer: (D) “This is only temporary; Stacy Clients with asthma don’t have any ammonia to urea. This results in
treated promptly as progression of the will re-grow new hair in 3-6 months, but particular characteristics, and clients with accumulation of ammonia and other toxic
tumor may result in paraplegia. The other may be different in texture”. in the blood that damages the cells.
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62. Answer: (C) “I’ll lower the dosage as diagnosis test. Nitroglycerin is an oral Rationale: Narcotics may mask changes in 75. Answer: (C) Myxedema coma
ordered so the drug causes only 2 to 4 sublingual medication. Cardiac the level of consciousness that indicate Rationale: Myxedema coma, severe
stools a day”. catheterization is a diagnostic tool – not a increased ICP and shouldn’t hypothyroidism, is a life-threatening
Rationale: Lactulose is given to a patients treatment. acetaminophen is strong enough ignores condition that may develop if thyroid
with hepatic encephalopathy to reduce 66. Answer: (B) Cardiogenic shock the mother’s question and therefore isn’t replacement medication isn't taken.
absorption of ammonia in the intestines Rationale: Cardiogenic shock is shock appropriate. Aspirin is contraindicated in Exophthalmos, protrusion of the eyeballs,
by binding with ammonia and promoting related to ineffective pumping of the conditions that may have bleeding, such is seen with hyperthyroidism. Thyroid
more frequent bowel movements. If the heart. Anaphylactic shock results from an as trauma, and for children or young storm is life-threatening but is caused by
patient experience diarrhea, it indicates allergic reaction. Distributive shock results adults with viral illnesses due to the severe hyperthyroidism. Tibial myxedema,
over dosage and the nurse must reduce from changes in the intravascular volume danger of Reye’s syndrome. Stronger peripheral mucinous edema involving the
the amount of medication given to the distribution and is usually associated with medications may not necessarily lead to lower leg, is associated with
patient. The stool will be mashy or soft. increased cardiac output. MI isn’t a shock vomiting but will sedate the client, hypothyroidism but isn't life-threatening.
Lactulose is also very sweet and may state, though a severe MI can lead to thereby masking changes in his level of 76. Answer: (B) An irregular apical pulse
cause cramping and bloating. shock. consciousness. Rationale: Because Cushing's syndrome
63. Answer: (B) Severe lower back pain, 67. Answer: (C) Kidneys’ excretion of sodium 71. Answer: (A) Appropriate; lowering carbon causes aldosterone overproduction, which
decreased blood pressure, decreased RBC and water dioxide (CO2) reduces intracranial increases urinary potassium loss, the
count, increased WBC count. Rationale: The kidneys respond to rise in pressure (ICP) disorder may lead to hypokalemia.
Rationale: Severe lower back pain blood pressure by excreting sodium and Rationale: A normal Paco2 value is 35 to Therefore, the nurse should immediately
indicates an aneurysm rupture, secondary excess water. This response ultimately 45 mm Hg CO2 has vasodilating report signs and symptoms of
to pressure being applied within the affects sysmolic blood pressure by properties; therefore, lowering Paco2 hypokalemia, such as an irregular apical
abdominal cavity. When ruptured occurs, regulating blood volume. Sodium or water through hyperventilation will lower ICP pulse, to the physician. Edema is an
the pain is constant because it can’t be retention would only further increase caused by dilated cerebral vessels. expected finding because aldosterone
alleviated until the aneurysm is repaired. blood pressure. Sodium and water travel Oxygenation is evaluated through Pao2 overproduction causes sodium and fluid
Blood pressure decreases due to the loss together across the membrane in the and oxygen saturation. Alveolar retention. Dry mucous membranes and
of blood. After the aneurysm ruptures, the kidneys; one can’t travel without the hypoventilation would be reflected in an frequent urination signal dehydration,
vasculature is interrupted and blood other. increased Paco2. which isn't associated with Cushing's
volume is lost, so blood pressure wouldn’t 68. Answer: (D) It inhibits reabsorption of 72. Answer: (B) A 33-year-old client with a syndrome.
increase. For the same reason, the RBC sodium and water in the loop of Henle. recent diagnosis of Guillain-Barre 77. Answer: (D) Below-normal urine
count is decreased – not increased. The Rationale: Furosemide is a loop diuretic syndrome osmolality level, above-normal serum
WBC count increases as cell migrate to the that inhibits sodium and water Rationale: Guillain-Barre syndrome is osmolality level
site of injury. reabsorption in the loop Henle, thereby characterized by ascending paralysis and Rationale: In diabetes insipidus, excessive
64. Answer: (D) Apply gloves and assess the causing a decrease in blood pressure. potential respiratory failure. The order of polyuria causes dilute urine, resulting in a
groin site Vasodilators cause dilation of peripheral client assessment should follow client below-normal urine osmolality level. At
Rationale: Observing standard precautions blood vessels, directly relaxing vascular priorities, with disorder of airways, the same time, polyuria depletes the body
is the first priority when dealing with any smooth muscle and decreasing blood breathing, and then circulation. There’s no of water, causing dehydration that leads
blood fluid. Assessment of the groin site is pressure. Adrenergic blockers decrease information to suggest the postmyocardial to an above-normal serum osmolality
the second priority. This establishes where sympathetic cardioacceleration and infarction client has an arrhythmia or level. For the same reasons, diabetes
the blood is coming from and determines decrease blood pressure. Angiotensin- other complication. There’s no evidence insipidus doesn't cause above-normal
how much blood has been lost. The goal in converting enzyme inhibitors decrease to suggest hemorrhage or perforation for urine osmolality or below-normal serum
this situation is to stop the bleeding. The blood pressure due to their action on the remaining clients as a priority of care. osmolality levels.
nurse would call for help if it were angiotensin. 73. Answer: (C) Decreases inflammation 78. Answer: (A) "I can avoid getting sick by not
warranted after the assessment of the 69. Answer: (C) Pancytopenia, elevated Rationale: Then action of colchicines is to becoming dehydrated and by paying
situation. After determining the extent of antinuclear antibody (ANA) titer decrease inflammation by reducing the attention to my need to urinate, drink, or
the bleeding, vital signs assessment is Rationale: Laboratory findings for clients migration of leukocytes to synovial fluid. eat more than usual."
important. The nurse should never move with SLE usually show pancytopenia, Colchicine doesn’t replace estrogen, Rationale: Inadequate fluid intake during
the client, in case a clot has formed. elevated ANA titer, and decreased serum decrease infection, or decrease bone hyperglycemic episodes often leads to
Moving can disturb the clot and cause complement levels. Clients may have demineralization. HHNS. By recognizing the signs of
rebleeding. elevated BUN and creatinine levels from 74. Answer: (C) Osteoarthritis is the most hyperglycemia (polyuria, polydipsia, and
65. Answer: (D) Percutaneous transluminal nephritis, but the increase does not common form of arthritis polyphagia) and increasing fluid intake,
coronary angioplasty (PTCA) indicate SLE. Rationale: Osteoarthritis is the most the client may prevent HHNS. Drinking a
Rationale: PTCA can alleviate the blockage 70. Answer: (C) Narcotics are avoided after a common form of arthritis and can be glass of nondiet soda would be
and restore blood flow and oxygenation. head injury because they may hide a extremely debilitating. It can afflict people appropriate for hypoglycemia. A client
An echocardiogram is a noninvasive worsening condition. of any age, although most are elderly. whose diabetes is controlled with oral
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antidiabetic agents usually doesn't need dangerously imbalanced. Temperature Rationale: A client with HHNS has an He could develop atelectasis but it
to monitor blood glucose levels. A high- regulation may be affected by excess overall body deficit of potassium resulting typically doesn’t produce progressive
carbohydrate diet would exacerbate the cortisol and isn't an accurate indicator of from diuresis, which occurs secondary to hypoxia.
client's condition, particularly if fluid infection. the hyperosmolar, hyperglycemic state 92. Answer: (D) Spontaneous pneumothorax
intake is low. 83. Answer: (C) onset to be at 2:30 p.m. and caused by the relative insulin deficiency. Rationale: A spontaneous pneumothorax
79. Answer: (D) Hyperparathyroidism its peak to be at 4 p.m. An elevated serum acetone level and occurs when the client’s lung collapses,
Rationale: Hyperparathyroidism is most Rationale: Regular insulin, which is a serum ketone bodies are characteristic of causing an acute decreased in the amount
common in older women and is short-acting insulin, has an onset of 15 to diabetic ketoacidosis. Metabolic acidosis, of functional lung used in oxygenation.
characterized by bone pain and weakness 30 minutes and a peak of 2 to 4 hours. not serum alkalosis, may occur in HHNS. The sudden collapse was the cause of his
from excess parathyroid hormone (PTH). Because the nurse gave the insulin at 2 87. Answer: (D) Maintaining room chest pain and shortness of breath. An
Clients also exhibit hypercaliuria-causing p.m., the expected onset would be from temperature in the low-normal range asthma attack would show wheezing
polyuria. While clients with diabetes 2:15 p.m. to 2:30 p.m. and the peak from Rationale: Graves' disease causes signs breath sounds, and bronchitis would have
mellitus and diabetes insipidus also have 4 p.m. to 6 p.m. and symptoms of hypermetabolism, such rhonchi. Pneumonia would have bronchial
polyuria, they don't have bone pain and 84. Answer: (A) No increase in the thyroid- as heat intolerance, diaphoresis, excessive breath sounds over the area of
increased sleeping. Hypoparathyroidism is stimulating hormone (TSH) level after 30 thirst and appetite, and weight loss. To consolidation.
characterized by urinary frequency rather minutes during the TSH stimulation test reduce heat intolerance and diaphoresis, 93. Answer: (C) Pneumothorax
than polyuria. Rationale: In the TSH test, failure of the the nurse should keep the client's room Rationale: From the trauma the client
80. Answer: (C) "I'll take two-thirds of the TSH level to rise after 30 minutes confirms temperature in the low-normal range. To experienced, it’s unlikely he has
dose when I wake up and one-third in the hyperthyroidism. A decreased TSH level replace fluids lost via diaphoresis, the bronchitis, pneumonia, or TB; rhonchi
late afternoon." indicates a pituitary deficiency of this nurse should encourage, not restrict, with bronchitis, bronchial breath sounds
Rationale: Hydrocortisone, a hormone. Below-normal levels of T3 and intake of oral fluids. Placing extra blankets with TB would be heard.
glucocorticoid, should be administered T4, as detected by radioimmunoassay, on the bed of a client with heat 94. Answer: (C) Serous fluids fills the space
according to a schedule that closely signal hypothyroidism. A below-normal T4 intolerance would cause discomfort. To and consolidates the region
reflects the bodies own secretion of this level also occurs in malnutrition and liver provide needed energy and calories, the Rationale: Serous fluid fills the space and
hormone; therefore, two-thirds of the disease and may result from nurse should encourage the client to eat eventually consolidates, preventing
dose of hydrocortisone should be taken in administration of phenytoin and certain high-carbohydrate foods. extensive mediastinal shift of the heart
the morning and one-third in the late other drugs. 88. Answer: (A) Fracture of the distal radius and remaining lung. Air can’t be left in the
afternoon. This dosage schedule reduces 85. Answer: (B) "Rotate injection sites within Rationale: Colles' fracture is a fracture of space. There’s no gel that can be placed in
adverse effects. the same anatomic region, not among the distal radius, such as from a fall on an the pleural space. The tissue from the
81. Answer: (C) High corticotropin and high different regions." outstretched hand. It's most common in other lung can’t cross the mediastinum,
cortisol levels Rationale: The nurse should instruct the women. Colles' fracture doesn't refer to a although a temporary mediastinal shift
Rationale: A corticotropin-secreting client to rotate injection sites within the fracture of the olecranon, humerus, or exits until the space is filled.
pituitary tumor would cause high same anatomic region. Rotating sites carpal scaphoid. 95. Answer: (A) Alveolar damage in the
corticotropin and high cortisol levels. A among different regions may cause 89. Answer: (B) Calcium and phosphorous infracted area
high corticotropin level with a low cortisol excessive day-to-day variations in the Rationale: In osteoporosis, bones lose Rationale: The infracted area produces
level and a low corticotropin level with a blood glucose level; also, insulin calcium and phosphate salts, becoming alveolar damage that can lead to the
low cortisol level would be associated absorption differs from one region to the porous, brittle, and abnormally vulnerable production of bloody sputum, sometimes
with hypocortisolism. Low corticotropin next. Insulin should be injected only into to fracture. Sodium and potassium aren't in massive amounts. Clot formation
and high cortisol levels would be seen if healthy tissue lacking large blood vessels, involved in the development of usually occurs in the legs. There’s a loss of
there was a primary defect in the adrenal nerves, or scar tissue or other deviations. steoporosis. lung parenchyma and subsequent scar
glands. Injecting insulin into areas of hypertrophy 90. Answer: (A) Adult respiratory distress tissue formation.
82. Answer: (D) Performing capillary glucose may delay absorption. The client shouldn't syndrome (ARDS) 96. Answer: (D) Respiratory alkalosis
testing every 4 hours inject insulin into areas of lipodystrophy Rationale: Severe hypoxia after smoke Rationale: A client with massive
Rationale: The nurse should perform (such as hypertrophy or atrophy); to inhalation is typically related to ARDS. The pulmonary embolism will have a large
capillary glucose testing every 4 hours prevent lipodystrophy, the client should other conditions listed aren’t typically region and blow off large amount of
because excess cortisol may cause insulin rotate injection sites systematically. associated with smoke inhalation and carbon dioxide, which crosses the
resistance, placing the client at risk for Exercise speeds drug absorption, so the severe hypoxia. unaffected alveolar-capillary membrane
hyperglycemia. Urine ketone testing isn't client shouldn't inject insulin into sites 91. Answer: (D) Fat embolism more readily than does oxygen and results
indicated because the client does secrete above muscles that will be exercised Rationale: Long bone fractures are in respiratory alkalosis.
insulin and, therefore, isn't at risk for heavily. correlated with fat emboli, which cause 97. Answer: (A) Air leak
ketosis. Urine specific gravity isn't 86. Answer: (D) Below-normal serum shortness of breath and hypoxia. It’s Rationale: Bubbling in the water seal
indicated because although fluid balance potassium level unlikely the client has developed asthma chamber of a chest drainage system stems
can be compromised, it usually isn't or bronchitis without a previous history. from an air leak. In pneumothorax an air
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leak can occur as air is pulled from the TEST V - Care of Clients with Physiologic and d. Suggest that the father and son work
pleural space. Bubbling doesn’t normally Psychosocial Alterations things out.
occur with either adequate or inadequate
suction or any preexisting bubbling in the 1. Mr. Marquez reports of losing his job, not being 5. What is Nurse John likely to note in a male client
water seal chamber. able to sleep at night, and feeling upset with his being admitted for alcohol withdrawal?
98. Answer: (B) 21 wife. Nurse John responds to the client, “You a. Perceptual disorders.
Rationale: 3000 x 10 divided by 24 x 60. may want to talk about your employment b. Impending coma.
99. Answer: (B) 2.4 ml situation in group today.” The Nurse is using c. Recent alcohol intake.
Rationale: .05 mg/ 1 ml = .12mg/ x ml, which therapeutic technique? d. Depression with mutism.
.05x = .12, x = 2.4 ml. a. Observations
100. Answer: (D) “I should put on the stockings b. Restating 6. Aira has taken amitriptyline HCL (Elavil) for 3
before getting out of bed in the morning. c. Exploring days, but now complains that it “doesn’t help”
Rationale: Promote venous return by d. Focusing and refuses to take it. What should the nurse say
applying external pressure on veins. or do?
2. Tony refuses his evening dose of Haloperidol a. Withhold the drug.
(Haldol), then becomes extremely agitated in the b. Record the client’s response.
dayroom while other clients are watching c. Encourage the client to tell the doctor.
television. He begins cursing and throwing d. Suggest that it takes a while before
furniture. Nurse Oliver first action is to: seeing the results.
a. Check the client’s medical record for an
order for an as-needed I.M. dose of 7. Dervid, an adolescent has a history of truancy
medication for agitation. from school, running away from home and
b. Place the client in full leather restraints. “barrowing” other people’s things without their
c. Call the attending physician and report permission. The adolescent denies stealing,
the behavior. rationalizing instead that as long as no one was
d. Remove all other clients from the using the items, it was all right to borrow them.
dayroom. It is important for the nurse to understand the
psychodynamically, this behavior may be largely
3. Tina who is manic, but not yet on medication, attributed to a developmental defect related to
comes to the drug treatment center. The nurse the:
would not let this client join the group session a. Id
because: b. Ego
a. The client is disruptive. c. Superego
b. The client is harmful to self. d. Oedipal complex
c. The client is harmful to others.
d. The client needs to be on medication 8. In preparing a female client for electroconvulsive
first. therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered
4. Dervid, an adolescent boy was admitted for for which therapeutic effect?
substance abuse and hallucinations. The client’s a. Short-acting anesthesia
mother asks Nurse Armando to talk with his b. Decreased oral and respiratory
husband when he arrives at the hospital. The secretions.
mother says that she is afraid of what the father c. Skeletal muscle paralysis.
might say to the boy. The most appropriate d. Analgesia.
nursing intervention would be to:
a. Inform the mother that she and the 9. Nurse Gina is aware that the dietary implications
father can work through this problem for a client in manic phase of bipolar disorder is:
themselves. a. Serve the client a bowl of soup, buttered
b. Refer the mother to the hospital social French bread, and apple slices.
worker. b. Increase calories, decrease fat, and
c. Agree to talk with the mother and the decrease protein.
father together. c. Give the client pieces of cut-up steak,
carrots, and an apple.
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d. Increase calories, carbohydrates, and deal with this conflict if you want to walk a. Antidepressants d. A low tolerance for frustration
protein. again." b. Anticholinergics
b. "It must be awful not to be able to move c. Antipsychotics 22. Nurse Amy is providing care for a male client
10. What parental behavior toward a child during an your legs. You may feel better if you d. Mood stabilizers undergoing opiate withdrawal. Opiate
admission procedure should cause Nurse Ron to realize the problem is psychological, not withdrawal causes severe physical discomfort
suspect child abuse? physical." 18. A client seeks care because she feels depressed and can be life-threatening. To minimize these
a. Flat affect c. "Your problem is real but there is no and has gained weight. To treat her atypical effects, opiate users are commonly detoxified
b. Expressing guilt physical basis for it. We'll work on what depression, the physician prescribes with:
c. Acting overly solicitous toward the child. is going on in your life to find out why tranylcypromine sulfate (Parnate), 10 mg by a. Barbiturates
d. Ignoring the child. it's happened." mouth twice per day. When this drug is used to b. Amphetamines
d. "It isn't uncommon for someone with treat atypical depression, what is its onset of c. Methadone
11. Nurse Lynnette notices that a female client with your personality to develop a conversion action? d. Benzodiazepines
obsessive-compulsive disorder washes her hands disorder during times of stress." a. 1 to 2 days
for long periods each day. How should the nurse b. 3 to 5 days 23. Nurse Cristina is caring for a client who
respond to this compulsive behavior? 14. Nurse Krina knows that the following drugs have c. 6 to 8 days experiences false sensory perceptions with no
a. By designating times during which the been known to be effective in treating d. 10 to 14 days basis in reality. These perceptions are known as:
client can focus on the behavior. obsessive-compulsive disorder (OCD): a. Delusions
b. By urging the client to reduce the a. benztropine (Cogentin) and 19. A 65 years old client is in the first stage of b. Hallucinations
frequency of the behavior as rapidly as diphenhydramine (Benadryl). Alzheimer's disease. Nurse Patricia should plan c. Loose associations
possible. b. chlordiazepoxide (Librium) and to focus this client's care on: d. Neologisms
c. By calling attention to or attempting to diazepam (Valium) a. Offering nourishing finger foods to help
prevent the behavior. c. fluvoxamine (Luvox) and clomipramine maintain the client's nutritional status. 24. Nurse Marco is developing a plan of care for a
d. By discouraging the client from (Anafranil) b. Providing emotional support and client with anorexia nervosa. Which action
verbalizing anxieties. d. divalproex (Depakote) and lithium individual counseling. should the nurse include in the plan?
(Lithobid) c. Monitoring the client to prevent minor a. Restricts visits with the family and
12. After seeking help at an outpatient mental illnesses from turning into major friends until the client begins to eat.
health clinic, Ruby who was raped while walking 15. Alfred was newly diagnosed with anxiety problems. b. Provide privacy during meals.
her dog is diagnosed with posttraumatic stress disorder. The physician prescribed buspirone d. Suggesting new activities for the client c. Set up a strict eating plan for the client.
disorder (PTSD). Three months later, Ruby (BuSpar). The nurse is aware that the teaching and family to do together. d. Encourage the client to exercise, which
returns to the clinic, complaining of fear, loss of instructions for newly prescribed buspirone will reduce her anxiety.
control, and helpless feelings. Which nursing should include which of the following? 20. The nurse is assessing a client who has just been
intervention is most appropriate for Ruby? a. A warning about the drugs delayed admitted to the emergency department. Which 25. Tim is admitted with a diagnosis of delusions of
a. Recommending a high-protein, low-fat therapeutic effect, which is from 14 to signs would suggest an overdose of an grandeur. The nurse is aware that this diagnosis
diet. 30 days. antianxiety agent? reflects a belief that one is:
b. Giving sleep medication, as prescribed, b. A warning about the incidence of a. Combativeness, sweating, and confusion a. Highly important or famous.
to restore a normal sleep- wake cycle. neuroleptic malignant syndrome (NMS). b. Agitation, hyperactivity, and grandiose b. Being persecuted
c. Allowing the client time to heal. c. A reminder of the need to schedule ideation c. Connected to events unrelated to
d. Exploring the meaning of the traumatic blood work in 1 week to check blood c. Emotional lability, euphoria, and oneself
event with the client. levels of the drug. impaired memory d. Responsible for the evil in the world.
d. A warning that immediate sedation can d. Suspiciousness, dilated pupils, and
13. Meryl, age 19, is highly dependent on her occur with a resultant drop in pulse. increased blood pressure 26. Nurse Jen is caring for a male client with manic
parents and fears leaving home to go away to depression. The plan of care for a client in a
college. Shortly before the semester starts, she 16. Richard with agoraphobia has been symptom- 21. The nurse is caring for a client diagnosed with manic state would include:
complains that her legs are paralyzed and is free for 4 months. Classic signs and symptoms of antisocial personality disorder. The client has a a. Offering a high-calorie meals and
rushed to the emergency department. When phobias include: history of fighting, cruelty to animals, and strongly encouraging the client to finish
physical examination rules out a physical cause a. Insomnia and an inability to concentrate. stealing. Which of the following traits would the all food.
for her paralysis, the physician admits her to the b. Severe anxiety and fear. nurse be most likely to uncover during b. Insisting that the client remain active
psychiatric unit where she is diagnosed with c. Depression and weight loss. assessment? through the day so that he’ll sleep at
conversion disorder. Meryl asks the nurse, "Why d. Withdrawal and failure to distinguish a. History of gainful employment night.
has this happened to me?" What is the nurse's reality from fantasy. b. Frequent expression of guilt regarding c. Allowing the client to exhibit
best response? antisocial behavior hyperactive, demanding, manipulative
a. "You've developed this paralysis so you 17. Which medications have been found to help c. Demonstrated ability to maintain close, behavior without setting limits.
can stay with your parents. You must reduce or eliminate panic attacks? stable relationships
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d. Listening attentively with a neutral 32. The nurse is aware that the side effect of c. Diverse interest
attitude and avoiding power struggles. electroconvulsive therapy that a client may d. Over meticulousness 43. When establishing an initial nurse-client
experience: relationship, Nurse Hazel should explore with
27. Ramon is admitted for detoxification after a a. Loss of appetite 38. Nurse Krina recognizes that the suicidal risk for the client the:
cocaine overdose. The client tells the nurse that b. Postural hypotension depressed client is greatest: a. Client’s perception of the presenting
he frequently uses cocaine but that he can c. Confusion for a time after treatment a. As their depression begins to improve problem.
control his use if he chooses. Which coping d. Complete loss of memory for a time b. When their depression is most severe b. Occurrence of fantasies the client may
mechanism is he using? 33. A dying male client gradually moves toward c. Before any type of treatment is started experience.
a. Withdrawal resolution of feelings regarding impending d. As they lose interest in the environment c. Details of any ritualistic acts carried out
b. Logical thinking death. Basing care on the theory of Kubler-Ross, by the client
c. Repression Nurse Trish plans to use nonverbal interventions 39. Nurse Kate would expect that a client with d. Client’s feelings when external; controls
d. Denial when assessment reveals that the client is in the: vascular dementis would experience: are instituted.
a. Anger stage a. Loss of remote memory related to
28. Richard is admitted with a diagnosis of b. Denial stage anoxia 44. Tranylcypromine sulfate (Parnate) is prescribed
schizotypal personality disorder. hich signs c. Bargaining stage b. Loss of abstract thinking related to for a depressed client who has not responded to
would this client exhibit during social situations? d. Acceptance stage emotional state the tricyclic antidepressants. After teaching the
a. Aggressive behavior c. Inability to concentrate related to client about the medication, Nurse Marian
b. Paranoid thoughts 34. The outcome that is unrelated to a crisis state is: decreased stimuli evaluates that learning has occurred when the
c. Emotional affect a. Learning more constructive coping skills d. Disturbance in recalling recent events client states, “I will avoid:
d. Independence needs b. Decompensation to a lower level of related to cerebral hypoxia. a. Citrus fruit, tuna, and yellow
functioning. vegetables.”
29. Nurse Mickey is caring for a client diagnosed c. Adaptation and a return to a prior level 40. Josefina is to be discharged on a regimen of b. Chocolate milk, aged cheese, and
with bulimia. The most appropriate initial goal of functioning. lithium carbonate. In the teaching plan for yogurt’”
for a client diagnosed with bulimia is to: d. A higher level of anxiety continuing for discharge the nurse should include: c. Green leafy vegetables, chicken, and
a. Avoid shopping for large amounts of more than 3 months. a. Advising the client to watch the diet milk.”
food. carefully d. Whole grains, red meats, and
b. Control eating impulses. 35. Miranda a psychiatric client is to be discharged b. Suggesting that the client take the pills carbonated soda.”
c. Identify anxiety-causing situations with orders for haloperidol (haldol) therapy. with milk
d. Eat only three meals per day. When developing a teaching plan for discharge, c. Reminding the client that a CBC must be 45. Nurse John is a aware that most crisis situations
the nurse should include cautioning the client done once a month. should resolve in about:
30. Rudolf is admitted for an overdose of against: d. Encouraging the client to have blood a. 1 to 2 weeks
amphetamines. When assessing the client, the a. Driving at night levels checked as ordered. b. 4 to 6 weeks
nurse should expect to see: b. Staying in the sun c. 4 to 6 months
a. Tension and irritability c. Ingesting wines and cheeses 41. The psychiatrist orders lithium carbonate 600 d. 6 to 12 months
b. Slow pulse d. Taking medications containing aspirin mg p.o t.i.d for a female client. Nurse Katrina
c. Hypotension would be aware that the teachings about the 46. Nurse Judy knows that statistics show that in
d. Constipation 36. Jen a nursing student is anxious about the side effects of this drug were understood when adolescent suicide behavior:
upcoming board examination but is able to study the client state, “I will call my doctor a. Females use more dramatic methods
31. Nicolas is experiencing hallucinations tells the intently and does not become distracted by a immediately if I notice any: than males
nurse, “The voices are telling me I’m no good.” roommate’s talking and loud music. The a. Sensitivity to bright light or sun b. Males account for more attempts than
The client asks if the nurse hears the voices. The student’s ability to ignore distractions and to b. Fine hand tremors or slurred speech do females
most appropriate response by the nurse would focus on studying demonstrates: c. Sexual dysfunction or breast c. Females talk more about suicide before
be: a. Mild-level anxiety enlargement attempting it
a. “It is the voice of your conscience, which b. Panic-level anxiety d. Inability to urinate or difficulty when d. Males are more likely to use lethal
only you can control.” c. Severe-level anxiety urinating methods than are females
b. “No, I do not hear your voices, but I d. Moderate-level anxiety
believe you can hear them”. 42. Nurse Mylene recognizes that the most 47. Dervid with paranoid schizophrenia repeatedly
c. “The voices are coming from within you 37. When assessing a premorbid personality important factor necessary for the establishment uses profanity during an activity therapy session.
and only you can hear them.” characteristic of a client with a major of trust in a critical care area is: Which response by the nurse would be most
d. “Oh, the voices are a symptom of your depression, it would be unusual for the nurse to a. Privacy appropriate?
illness; don’t pay any attention to them.” find that this client demonstrated: b. Respect a. "Your behavior won't be tolerated. Go to
a. Rigidity c. Empathy your room immediately."
b. Stubbornness d. Presence
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b. "You're just doing this to get back at me 52. Mr. Cruz visits the physician's office to seek 57. Edward, a 66 year old client with slight memory
for making you come to therapy." treatment for depression, feelings of impairment and poor concentration is diagnosed 61. Mr. Garcia, an attorney who throws books and
c. "Your cursing is interrupting the activity. hopelessness, poor appetite, insomnia, fatigue, with primary degenerative dementia of the furniture around the office after losing a case is
Take time out in your room for 10 low self- esteem, poor concentration, and Alzheimer's type. Early signs of this dementia referred to the psychiatric nurse in the law firm's
minutes." difficulty making decisions. The client states that include subtle personality changes and employee assistance program. Nurse Beatriz
d. "I'm disappointed in you. You can't these symptoms began at least 2 years ago. withdrawal from social interactions. To assess knows that the client's behavior most likely
control yourself even for a few minutes." Based on this report, the nurse Tyfany suspects: for progression to the middle stage of represents the use of which defense
a. Cyclothymic disorder. Alzheimer's disease, the nurse should observe mechanism?
48. Nurse Maureen knows that the nonantipsychotic b. Atypical affective disorder. the client for: a. Regression
medication used to treat some clients with c. Major depression. a. Occasional irritable outbursts. b. Projection
schizoaffective disorder is: d. Dysthymic disorder. b. Impaired communication. c. Reaction-formation
a. phenelzine (Nardil) c. Lack of spontaneity. d. Intellectualization
b. chlordiazepoxide (Librium) 53. After taking an overdose of phenobarbital d. Inability to perform self-care activities.
c. lithium carbonate (Lithane) (Barbita), Mario is admitted to the emergency 62. Nurse Anne is caring for a client who has been
d. imipramine (Tofranil) department. Dr. Trinidad prescribes activated 58. Isabel with a diagnosis of depression is started treated long term with antipsychotic medication.
charcoal (Charcocaps) to be administered by on imipramine (Tofranil), 75 mg by mouth at During the assessment, Nurse Anne checks the
49. Which information is most important for the mouth immediately. Before administering the bedtime. The nurse should tell the client that: client for tardive dyskinesia. If tardive dyskinesia
nurse Trinity to include in a teaching plan for a dose, the nurse verifies the dosage ordered. a. This medication may be habit forming is present, Nurse Anne would most likely
male schizophrenic client taking clozapine What is the usual minimum dose of activated and will be discontinued as soon as the observe:
(Clozaril)? charcoal? client feels better. a. Abnormal movements and involuntary
a. Monthly blood tests will be necessary. a. 5 g mixed in 250 ml of water b. This medication has no serious adverse movements of the mouth, tongue, and
b. Report a sore throat or fever to the b. 15 g mixed in 500 ml of water effects. face.
physician immediately. c. 30 g mixed in 250 ml of water c. The client should avoid eating such b. Abnormal breathing through the nostrils
c. Blood pressure must be monitored for d. 60 g mixed in 500 ml of water foods as aged cheeses, yogurt, and accompanied by a “thrill.”
hypertension. chicken livers while taking the c. Severe headache, flushing, tremors, and
d. Stop the medication when symptoms 54. What herbal medication for depression, widely medication. ataxia.
subside. used in Europe, is now being prescribed in the d. This medication may initially cause d. Severe hypertension, migraine
United States? tiredness, which should become less headache,
50. Ricky with chronic schizophrenia takes a. Ginkgo biloba bothersome over time.
neuroleptic medication is admitted to the b. Echinacea 63. Dennis has a lithium level of 2.4 mEq/L. The
psychiatric unit. Nursing assessment reveals c. St. John's wort 59. Kathleen is admitted to the psychiatric clinic for nurse immediately would assess the client for
rigidity, fever, hypertension, and diaphoresis. d. Ephedra treatment of anorexia nervosa. To promote the which of the following signs or symptoms?
These findings suggest which life- threatening client's physical health, the nurse should plan to: a. Weakness
reaction: 55. Cely with manic episodes is taking lithium. a. Severely restrict the client's physical b. Diarrhea
a. Tardive dyskinesia. Which electrolyte level should the nurse check activities. c. Blurred vision
b. Dystonia. before administering this medication? b. Weigh the client daily, after the evening d. Fecal incontinence
c. Neuroleptic malignant syndrome. a. Clcium meal.
d. Akathisia. b. Sodium c. Monitor vital signs, serum electrolyte 64. Nurse Jannah is monitoring a male client who
c. Chloride levels, and acid-base balance. has been placed inrestraints because of violent
51. Which nursing intervention would be most d. Potassium d. Instruct the client to keep an accurate behavior. Nurse determines that it will be safe to
appropriate if a male client develop orthostatic record of food and fluid intake. remove the restraints when:
hypotension while taking amitriptyline (Elavil)? 56. Nurse Josefina is caring for a client who has been a. The client verbalizes the reasons for the
a. Consulting with the physician about diagnosed with delirium. Which statement about 60. Celia with a history of polysubstance abuse is violent behavior.
substituting a different type of delirium is true? admitted to the facility. She complains of nausea b. The client apologizes and tells the nurse
antidepressant. a. It's characterized by an acute onset and and vomiting 24 hours after admission. The that it will never happen again.
b. Advising the client to sit up for 1 minute lasts about 1 month. nurse assesses the client and notes piloerection, c. No acts of aggression have been
before getting out of bed. b. It's characterized by a slowly evolving pupillary dilation, and lacrimation. The nurse observed within 1 hour after the release
c. Instructing the client to double the onset and lasts about 1 week. suspects that the client is going through which of of two of the extremity restraints.
dosage until the problem resolves. c. It's characterized by a slowly evolving the following withdrawals? d. The administered medication has taken
d. Informing the client that this adverse onset and lasts about 1 month. a. Alcohol withdrawal effect.
reaction should disappear within 1 d. It's characterized by an acute onset and b. Cannibis withdrawal
week. lasts hours to a number of days. c. Cocaine withdrawal
d. Opioid withdrawal
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65. Nurse Irish is aware that Ritalin is the drug of a. Revealing personal information to the d. It promotes emotional support or
choice for a child with ADHD. The side effects of client 77. Katrina, a newly admitted is extremely hostile attention for the client
the following may be noted by the nurse: b. Focusing on the feelings of the client. toward a staff member she has just met, without
a. Increased attention span and c. Confronting the client about apparent reason. According to Freudian theory, 82. Dervid is diagnosed with panic disorder with
concentration discrepancies in verbal or non-verbal the nurse should suspect that the client is agoraphobia is talking with the nurse in-charge
b. Increase in appetite behavior experiencing which of the following about the progress made in treatment. Which of
c. Sleepiness and lethargy d. The client feels angry towards the nurse phenomena? the following statements indicates a positive
d. Bradycardia and diarrhea who resembles his mother. a. Intellectualization client response?
b. Transference a. “I went to the mall with my friends last
66. Kitty, a 9 year old child has very limited 72. Tristan is on Lithium has suffered from diarrhea c. Triangulation Saturday”
vocabulary and interaction skills. She has an I.Q. and vomiting. What should the nurse in-charge d. Splitting b. “I’m hyperventilating only when I have a
of 45. She is diagnosed to have Mental do first: panic attack”
retardation of this classification: a. Recognize this as a drug interaction 78. An 83year-old male client is in extended care c. “Today I decided that I can stop taking
a. Profound b. Give the client Cogentin facility is anxious most of the time and my medication”
b. Mild c. Reassure the client that these are frequently complains of a number of vague d. “Last night I decided to eat more than a
c. Moderate common side effects of lithium therapy symptoms that interfere with his ability to eat. bowl of cereal”
d. Severe d. Hold the next dose and obtain an order These symptoms indicate which of the following
for a stat serum lithium level disorders? 83. The effectiveness of monoamine oxidase (MAO)
67. The therapeutic approach in the care of Armand a. Conversion disorder inhibitor drug therapy in a client with
an autistic child include the following EXCEPT: 73. Nurse Sarah ensures a therapeutic environment b. Hypochondriasis posttraumatic stress disorder can be
a. Engage in diversionary activities when for all the client. Which of the following best c. Severe anxiety demonstrated by which of the following client
acting -out describes a therapeutic milieu? d. Sublimation self –reports?
b. Provide an atmosphere of acceptance a. A therapy that rewards adaptive a. “I’m sleeping better and don’t have
c. Provide safety measures behavior 79. Charina, a college student who frequently visited nightmares”
d. Rearrange the environment to activate b. A cognitive approach to change behavior the health center during the past year with b. “I’m not losing my temper as much”
the child c. A living, learning or working multiple vague complaints of GI symptoms c. “I’ve lost my craving for alcohol”
environment. before course examinations. Although physical d. I’ve lost my phobia for water”
68. Jeremy is brought to the emergency room by d. A permissive and congenial environment causes have been eliminated, the student
friends who state that he took something an continues to express her belief that she has a 84. Mark, with a diagnosis of generalized anxiety
hour ago. He is actively hallucinating, agitated, 74. Anthony is very hostile toward one of the staff serious illness. These symptoms are typically of disorder wants to stop taking his lorazepam
with irritated nasal septum. for no apparent reason. He is manifesting: which of the following disorders? (Ativan). Which of the following important facts
a. Heroin a. Splitting a. Conversion disorder should nurse Betty discuss with the client about
b. Cocaine b. Transference b. Depersonalization discontinuing the medication?
c. LSD c. Countertransference c. Hypochondriasis a. Stopping the drug may cause depression
d. Marijuana d. Resistance d. Somatization disorder b. Stopping the drug increases cognitive
abilities
69. Nurse Pauline is aware that Dementia unlike 75. Marielle, 17 years old was sexually attacked 80. Nurse Daisy is aware that the following c. Stopping the drug decreases sleeping
delirium is characterized by: while on her way home from school. She is pharmacologic agents are sedative- hypnotic difficulties
a. Slurred speech brought to the hospital by her mother. Rape is medication is used to induce sleep for a client d. Stopping the drug can cause withdrawal
b. Insidious onset an example of which type of crisis: experiencing a sleep disorder is: symptoms
c. Clouding of consciousness a. Situational a. Triazolam (Halcion)
d. Sensory perceptual change b. Adventitious b. Paroxetine (Paxil)\ 85. Jennifer, an adolescent who is depressed and
c. Developmental c. Fluoxetine (Prozac) reported by his parents as having difficulty in
70. A 35 year old female has intense fear of riding an d. Internal d. Risperidone (Risperdal) school is brought to the community mental
elevator. She claims “ As if I will die inside.” The health center to be evaluated. Which of the
client is suffering from: 76. Nurse Greta is aware that the following is 81. Aldo, with a somatoform pain disorder may following other health problems would the nurse
a. Agoraphobia classified as an Axis I disorder by the Diagnosis obtain secondary gain. Which of the following suspect?
b. Social phobia and Statistical Manual of Mental Disorders, Text statement refers to a secondary gain? a. Anxiety disorder
c. Claustrophobia Revision (DSM-IV-TR) is: a. It brings some stability to the family b. Behavioral difficulties
d. Xenophobia a. Obesity b. It decreases the preoccupation with the c. Cognitive impairment
b. Borderline personality disorder physical illness d. Labile moods
71. Nurse Myrna develops a counter-transference c. Major depression c. It enables the client to avoid some
reaction. This is evidenced by: d. Hypertension unpleasant activity
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86. Ricardo, an outpatient in psychiatric facility is c. The client becomes anxious whenever a. “I’m not going to look just at the 100. Rocky has started taking haloperidol (Haldol).
diagnosed with dysthymic disorder. Which of the the nurse leaves the bedside negative things about myself” Which of the following instructions is most
following statement about dysthymic disorder is d. The client looks at the shadow on a wall b. “I’m most concerned about my level of appropriate for Ricky before taking
true? and tells the nurse she sees frightening competence and progress” haloperidol?
a. It involves a mood range from moderate faces on the wall. c. “I’m not as envious of the things other a. Should report feelings of restlessness or
depression to hypomania people have as I used to be” agitation at once
b. It involves a single manic depression 91. During conversation of Nurse John with a client, d. “I find I can’t stop myself from taking b. Use a sunscreen outdoors on a year-
c. It’s a form of depression that occurs in he observes that the client shift from one topic over things other should be doing” round basis
the fall and winter to the next on a regular basis. Which of the c. Be aware you’ll feel increased energy
d. It’s a mood disorder similar to major following terms describes this disorder? 96. Norma, a 42-year-old client with a diagnosis of taking this drug
depression but of mild to moderate a. Flight of ideas chronic undifferentiated schizophrenia lives in a d. This drug will indirectly control essential
severity b. Concrete thinking rooming house that has a weekly nursing clinic. hypertension
c. Ideas of reference She scratches while she tells the nurse she feels
87. The nurse is aware that the following ways in d. Loose association creatures eating away at her skin. Which of the
vascular dementia different from Alzheimer’s following interventions should be done first?
disease is: 92. Francis tells the nurse that her coworkers are a. Talk about his hallucinations and fears
a. Vascular dementia has more abrupt sabotaging the computer. When the nurse asks b. Refer him for anticholinergic adverse
onset questions, the client becomes argumentative. reactions
b. The duration of vascular dementia is This behavior shows personality traits associated c. Assess for possible physical problems
usually brief with which of the following personality disorder? such as rash
c. Personality change is common in a. Antisocial d. Call his physician to get his medication
vascular dementia b. Histrionic increased to control his psychosis
d. The inability to perform motor activities c. Paranoid
occurs in vascular dementia d. Schizotypal 97. Ivy, who is on the psychiatric unit is copying and
imitating the movements of her primary nurse.
88. Loretta, a newly admitted client was diagnosed 93. Which of the following interventions is During recovery, she says, “I thought the nurse
with delirium and has history of hypertension important for a Cely experiencing with paranoid was my mirror. I felt connected only when I saw
and anxiety. She had been taking digoxin, personality disorder taking olanzapine my nurse.” This behavior is known by which of
furosemide (Lasix), and diazepam (Valium) for (Zyprexa)? the following terms?
anxiety. This client’s impairment may be related a. Explain effects of serotonin syndrome a. Modeling
to which of the following conditions? b. Teach the client to watch for b. Echopraxia
a. Infection extrapyramidal adverse reaction c. Ego-syntonicity
b. Metabolic acidosis c. Explain that the drug is less affective if d. Ritualism
c. Drug intoxication the client smokes
d. Hepatic encephalopathy d. Discuss the need to report paradoxical 98. Jun approaches the nurse and tells that he hears
effects such as euphoria a voice telling him that he’s evil and deserves to
89. Nurse Ron enters a client’s room, the client says, die. Which of the following terms describes the
“They’re crawling on my sheets! Get them off 94. Nurse Alexandra notices other clients on the unit client’s perception?
my bed!” Which of the following assessment is avoiding a client diagnosed with antisocial a. Delusion
the most accurate? personality disorder. When discussing b. Disorganized speech
a. The client is experiencing aphasia appropriate behavior in group therapy, which of c. Hallucination
b. The client is experiencing dysarthria the following comments is expected about this d. Idea of reference
c. The client is experiencing a flight of ideas client by his peers?
d. The client is experiencing visual a. Lack of honesty 99. Mike is admitted to a psychiatric unit with a
hallucination b. Belief in superstition diagnosis of undifferentiated schizophrenia.
c. Show of temper tantrums Which of the following defense mechanisms is
90. Which of the following descriptions of a client’s d. Constant need for attention probably used by mike?
experience and behavior can be assessed as an a. Projection
illusion? 95. Tommy, with dependent personality disorder is b. Rationalization
a. The client tries to hit the nurse when working to increase his self- esteem. Which of c. Regression
vital signs must be taken the following statements by the Tommy shows d. Repression
b. The client says, “I keep hearing a voice teaching was successful?
telling me to run away”
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Answers and Rationale – Care of Clients with Rationale: This behavior is an example of 14. Answer: (C) fluvoxamine (Luvox) and Rationale: Clients in the first stage of Alzheimer's
Physiologic and Psychosocial Alterations reaction formation, a coping mechanism. clomipramine (Anafranil) disease are aware that something is happening
11. Answer: (A) By designating times during which Rationale: The antidepressants fluvoxamine and to them and may become overwhelmed and
1. Answer: (D) Focusing the client can focus on the behavior. clomipramine have been effective in the frightened. Therefore, nursing care typically
Rationale: The nurse is using focusing by Rationale: The nurse should designate times treatment of OCD. Librium and Valium may be focuses on providing emotional support and
suggesting that the client discuss a specific issue. during which the client can focus on the helpful in treating anxiety related to OCD but individual counseling. The other options are
The nurse didn’t restate the question, make compulsive behavior or obsessive thoughts. The aren't drugs of choice to treat the illness. The appropriate during the second stage of
observation, or ask further question (exploring). nurse should urge the client to reduce the other medications mentioned aren't effective in Alzheimer's disease, when the client needs
2. Answer: (D) Remove all other clients from the frequency of the compulsive behavior gradually, the treatment of OCD. continuous monitoring to prevent minor
dayroom. not rapidly. She shouldn't call attention to or try 15. Answer: (A) A warning about the drugs delayed illnesses from progressing into major problems
Rationale: The nurse’s first priority is to consider to prevent the behavior. Trying to prevent the therapeutic effect, which is from 14 to 30 days. and when maintaining adequate nutrition may
the safety of the clients in the therapeutic behavior may cause pain and terror in the client. Rationale: The client should be informed that become a challenge. During this stage, offering
setting. The other actions are appropriate The nurse should encourage the client to the drug's therapeutic effect might not be nourishing finger foods helps clients to feed
responses after ensuring the safety of other verbalize anxieties to help distract attention reached for 14 to 30 days. The client must be themselves and maintain adequate nutrition.
clients. from the compulsive behavior. instructed to continue taking the drug as 20. Answer: (C) Emotional lability, euphoria, and
3. Answer: (A) The client is disruptive. 12. Answer: (D) Exploring the meaning of the directed. Blood level checks aren't necessary. impaired memory
Rationale: Group activity provides too much traumatic event with the client. NMS hasn't been reported with this drug, but Rationale: Signs of antianxiety agent overdose
stimulation, which the client will not be able to Rationale: The client with PTSD needs tachycardia is frequently reported. include emotional lability, euphoria, and
handle (harmful to self) and as a result will be encouragement to examine and understand the 16. Answer: (B) Severe anxiety and fear. impaired memory. Phencyclidine overdose can
disruptive to others. meaning of the traumatic event and consequent Rationale: Phobias cause severe anxiety (such as cause combativeness, sweating, and confusion.
4. Answer: (C) Agree to talk with the mother and losses. Otherwise, symptoms may worsen and a panic attack) that is out of proportion to the Amphetamine overdose can result in agitation,
the father together. the client may become depressed or engage in threat of the feared object or situation. Physical hyperactivity, and grandiose ideation.
Rationale: By agreeing to talk with both parents, self-destructive behavior such as substance signs and symptoms of phobias include profuse Hallucinogen overdose can produce
the nurse can provide emotional support and abuse. The client must explore the meaning of sweating, poor motor control, tachycardia, and suspiciousness, dilated pupils, and increased
further assess and validate the family’s needs. the event and won't heal without this, no matter elevated blood pressure. Insomnia, an inability blood pressure.
5. Answer: (A) Perceptual disorders. how much time passes. Behavioral techniques, to concentrate, and weight loss are common in 21. Answer: (D) A low tolerance for frustration
Rationale: Frightening visual hallucinations are such as relaxation therapy, may help decrease depression. Withdrawal and failure to Rationale: Clients with an antisocial personality
especially common in clients experiencing the client's anxiety and induce sleep. The distinguish reality from fantasy occur in disorder exhibit a low tolerance for frustration,
alcohol withdrawal. physician may prescribe antianxiety agents or schizophrenia. emotional immaturity, and a lack of impulse
6. Answer: (D) Suggest that it takes a while before antidepressants cautiously to avoid dependence; 17. Answer: (A) Antidepressants control. They commonly have a history of
seeing the results. sleep medication is rarely appropriate. A special Rationale: Tricyclic and monoamine oxidase unemployment, miss work repeatedly, and quit
Rationale: The client needs a specific response; diet isn't indicated unless the client also has an (MAO) inhibitor antidepressants have been work without other plans for employment. They
that it takes 2 to 3 weeks (a delayed effect) until eating disorder or a nutritional problem. found to be effective in treating clients with don't feel guilt about their behavior and
the therapeutic blood level is reached. 13. Answer: (C) "Your problem is real but there is no panic attacks. Why these drugs help control commonly perceive themselves as victims. They
7. Answer: (C) Superego physical basis for it. We'll work on what is going panic attacks isn't clearly understood. also display a lack of responsibility for the
Rationale: This behavior shows a weak sense of on in your life to find out why it's happened." Anticholinergic agents, which are smooth- outcome of their actions. Because of a lack of
moral consciousness. According to Freudian Rationale: The nurse must be honest with the muscle relaxants, relieve physical symptoms of trust in others, clients with antisocial personality
theory, personality disorders stem from a weak client by telling her that the paralysis has no anxiety but don't relieve the anxiety itself. disorder commonly have difficulty developing
superego. physiologic cause while also conveying empathy Antipsychotic drugs are inappropriate because stable, close relationships.
8. Answer: (C) Skeletal muscle paralysis. and acknowledging that her symptoms are real. clients who experience panic attacks aren't 22. Answer: (C) Methadone
Rationale: Anectine is a depolarizing muscle The client will benefit from psychiatric psychotic. Mood stabilizers aren't indicated Rationale: Methadone is used to detoxify opiate
relaxant causing paralysis. It is used to reduce treatment, which will help her understand the because panic attacks are rarely associated with users because it binds with opioid receptors at
the intensity of muscle contractions during the underlying cause of her symptoms. After the mood changes. many sites in the central nervous system but
convulsive stage, thereby reducing the risk of psychological conflict is resolved, her symptoms 18. Answer: (B) 3 to 5 days doesn’t have the same deterious effects as other
bone fractures or dislocation. will disappear. Saying that it must be awful not Rationale: Monoamine oxidase inhibitors, such opiates, such as cocaine, heroin, and morphine.
9. Answer: (D) Increase calories, carbohydrates, to be able to move her legs wouldn't answer the as tranylcypromine, have an onset of action of Barbiturates, amphetamines, and
and protein. client's question; knowing that the cause is approximately 3 to 5 days. A full clinical benzodiazepines are highly addictive and would
Rationale: This client increased protein for tissue psychological wouldn't necessarily make her feel response may be delayed for 3 to 4 weeks. The require detoxification treatment.
building and increased calories to replace what is better. Telling her that she has developed therapeutic effects may continue for 1 to 2 23. Answer: (B) Hallucinations
burned up (usually via carbohydrates). paralysis to avoid leaving her parents or that her weeks after discontinuation. Rationale: Hallucinations are visual, auditory,
10. Answer: (C) Acting overly solicitous toward the personality caused her disorder wouldn't help 19. Answer: (B) Providing emotional support and gustatory, tactile, or olfactory perceptions that
child. her understand and resolve the underlying individual counseling. have no basis in reality. Delusions are false
conflict. beliefs, rather than perceptions, that the client
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accepts as real. Loose associations are rapid behavior is uncommon, although these clients 38. Answer: (A) As their depression begins to option A. Option B is incorrect because it implies
shifts among unrelated ideas. Neologisms are may experience agitation with anxiety. Their improve that the client’s actions reflect feelings toward
bizarre words that have meaning only to the behavior is emotionally cold with a flattened Rationale: At this point the client may have the staff instead of the client's own misery.
client. affect, regardless of the situation. These clients enough energy to plan and execute an attempt. Judgmental remarks, such as option D, may
24. Answer: (C) Set up a strict eating plan for the demonstrate a reduced capacity for close or 39. Answer: (D) Disturbance in recalling recent decrease the client's self-esteem.
client. dependent relationships. events related to cerebral hypoxia. 48. Answer: (C) lithium carbonate (Lithane)
Rationale: Establishing a consistent eating plan 29. Answer: (C) Identify anxiety-causing situations Rationale: Cell damage seems to interfere with Rationale: Lithium carbonate, an antimania drug,
and monitoring the client’s weight are very Rationale: Bulimic behavior is generally a registering input stimuli, which affects the ability is used to treat clients with cyclical
important in this disorder. The family and friends maladaptive coping response to stress and to register and recall recent events; vascular schizoaffective disorder, a psychotic disorder
should be included in the client’s care. The client underlying issues. The client must identify dementia is related to multiple vascular lesions once classified under schizophrenia that causes
should be monitored during meals-not given anxiety-causing situations that stimulate the of the cerebral cortex and subcortical structure. affective symptoms, including maniclike activity.
privacy. Exercise must be limited and supervised. bulimic behavior and then learn new ways of 40. Answer: (D) Encouraging the client to have blood Lithium helps control the affective component of
25. Answer: (A) Highly important or famous. coping with the anxiety. levels checked as ordered. this disorder. Phenelzine is a monoamine
Rationale: A delusion of grandeur is a false belief 30. Answer: (A) Tension and irritability Rationale: Blood levels must be checked monthly oxidase inhibitor prescribed for clients who don't
that one is highly important or famous. A Rationale: An amphetamine is a nervous system or bimonthly when the client is on maintenance respond to other antidepressant drugs such as
delusion of persecution is a false belief that one stimulant that is subject to abuse because of its therapy because there is only a small range imipramine. Chlordiazepoxide, an antianxiety
is being persecuted. A delusion of reference is a ability to produce wakefulness and euphoria. An between therapeutic and toxic levels. agent, generally is contraindicated in psychotic
false belief that one is connected to events overdose increases tension and irritability. 41. Answer: (B) Fine hand tremors or slurred speech clients. Imipramine, primarily considered an
unrelated to oneself or a belief that one is Options B and C are incorrect because Rationale: These are common side effects of antidepressant agent, is also used to treat clients
responsible for the evil in the world. amphetamines stimulate norepinephrine, which lithium carbonate. with agoraphobia and that undergoing cocaine
26. Answer: (D) Listening attentively with a neutral increase the heart rate and blood flow. Diarrhea 42. Answer: (D) Presence detoxification.
attitude and avoiding power struggles. is a common adverse effect so option D is Rationale: The constant presence of a nurse 49. Answer: (B) Report a sore throat or fever to the
Rationale: The nurse should listen to the client’s incorrect. provides emotional support because the client physician immediately.
requests, express willingness to seriously 31. Answer: (B) “No, I do not hear your voices, but I knows that someone is attentive and available in Rationale: A sore throat and fever are
consider the request, and respond later. The believe you can hear them”. case of an emergency. indications of an infection caused by
nurse should encourage the client to take short Rationale: The nurse, demonstrating knowledge 43. Answer: (A) Client’s perception of the presenting agranulocytosis, a potentially life-threatening
daytime naps because he expends so much and understanding, accepts the client’s problem. complication of clozapine. Because of the risk of
energy. The nurse shouldn’t try to restrain the perceptions even though they are hallucinatory. Rationale: The nurse can be most therapeutic by agranulocytosis, white blood cell (WBC) counts
client when he feels the need to move around as 32. Answer: (C) Confusion for a time after treatment starting where the client is, because it is the are necessary weekly, not monthly. If the WBC
long as his activity isn’t harmful. High calorie Rationale: The electrical energy passing through client’s concept of the problem that serves as count drops below 3,000/μl, the medication
finger foods should be offered to supplement the cerebral cortex during ECT results in a the starting point of the relationship. must be stopped. Hypotension may occur in
the client’s diet, if he can’t remain seated long temporary state of confusion after treatment. 44. Answer: (B) Chocolate milk, aged cheese, and clients taking this medication. Warn the client to
enough to eat a complete meal. The nurse 33. Answer: (D) Acceptance stage yogurt’” stand up slowly to avoid dizziness from
shouldn’t be forced to stay seated at the table to Rationale: Communication and intervention Rationale: These high-tyramine foods, when orthostatic hypotension. The medication should
finid=sh a meal. The nurse should set limits in a during this stage are mainly nonverbal, as when ingested in the presence of an MAO inhibitor, be continued, even when symptoms have been
calm, clear, and self-confident tone of voice. the client gestures to hold the nurse’s hand. cause a severe hypertensive response. controlled. If the medication must be stopped, it
27. Answer: (D) Denial 34. Answer: (D) A higher level of anxiety continuing 45. Answer: (B) 4 to 6 weeks should be slowly tapered over 1 to 2 weeks and
Rationale: Denial is unconscious defense for more than 3 months. Rationale: Crisis is self-limiting and lasts from 4 only under the supervision of a physician.
mechanism in which emotional conflict and Rationale: This is not an expected outcome of a to 6 weeks. 50. Answer: (C) Neuroleptic malignant syndrome.
anxiety is avoided by refusing to acknowledge crisis because by definition a crisis would be 46. Answer: (D) Males are more likely to use lethal Rationale: The client's signs and symptoms
feelings, desires, impulses, or external facts that resolved in 6 weeks. methods than are females suggest neuroleptic malignant syndrome, a life-
are consciously intolerable. Withdrawal is a 35. Answer: (B) Staying in the sun Rationale: This finding is supported by research; threatening reaction to neuroleptic medication
common response to stress, characterized by Rationale: Haldol causes photosensitivity. Severe females account for 90% of suicide attempts but that requires immediate treatment. Tardive
apathy. Logical thinking is the ability to think sunburn can occur on exposure to the sun. males are three times more successful because dyskinesia causes involuntary movements of the
rationally and make responsible decisions, which 36. Answer: (D) Moderate-level anxiety of methods used. tongue, mouth, facial muscles, and arm and leg
would lead the client admitting the problem and Rationale: A moderately anxious person can 47. Answer: (C) "Your cursing is interrupting the muscles. Dystonia is characterized by cramps
seeking help. Repression is suppressing past ignore peripheral events and focuses on central activity. Take time out in your room for 10 and rigidity of the tongue, face, neck, and back
events from the consciousness because of guilty concerns. minutes." muscles. Akathisia causes restlessness, anxiety,
association. 37. Answer: (C) Diverse interest Rationale: The nurse should set limits on client and jitteriness.
28. Answer: (B) Paranoid thoughts Rationale: Before onset of depression, these behavior to ensure a comfortable environment 51. Answer: (B) Advising the client to sit up for 1
Rationale: Clients with schizotypal personality clients usually have very narrow, limited for all clients. The nurse should accept hostile or minute before getting out of bed.
disorder experience excessive social anxiety that interest. quarrelsome client outbursts within limits Rationale: To minimize the effects of
can lead to paranoid thoughts. Aggressive without becoming personally offended, as in amitriptyline-induced orthostatic hypotension,
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the nurse should advise the client to sit up for 1 functions but sodium is most important to the than one obtained after the evening meal. 65. Answer: (A) increased attention span and
minute before getting out of bed. Orthostatic absorption of lithium. Option D would reward the client with attention concentration
hypotension commonly occurs with tricyclic 56. Answer: (D) It's characterized by an acute onset for not eating and reinforce the control issues Rationale: The medication has a paradoxic effect
antidepressant therapy. In these cases, the and lasts hours to a number of days that are central to the underlying psychological that decreases hyperactivity and impulsivity
dosage may be reduced or the physician may Rationale: Delirium has an acute onset and problem; also, the client may record food and among children with ADHD. B, C, D. Side effects
prescribe nortriptyline, another tricyclic typically can last from several hours to several fluid intake inaccurately. of Ritalin include anorexia, insomnia, diarrhea
antidepressant. Orthostatic hypotension days. 60. Answer: (D) Opioid withdrawal and irritability.
disappears only when the drug is discontinued. 57. Answer: (B) Impaired communication. Rationale: The symptoms listed are specific to 66. Answer: (C) Moderate
52. Answer: (D) Dysthymic disorder. Rationale: Initially, memory impairment may be opioid withdrawal. Alcohol withdrawal would Rationale: The child with moderate mental
Rationale: Dysthymic disorder is marked by the only cognitive deficit in a client with show elevated vital signs. There is no real retardation has an I.Q. of 35- 50 Profound
feelings of depression lasting at least 2 years, Alzheimer's disease. During the early stage of withdrawal from cannibis. Symptoms of cocaine Mental retardation has an I.Q. of below 20; Mild
accompanied by at least two of the following this disease, subtle personality changes may also withdrawal include depression, anxiety, and mental retardation 50-70 and Severe mental
symptoms: sleep disturbance, appetite be present. However, other than occasional agitation. retardation has an I.Q. of 20-35.
disturbance, low energy or fatigue, low self- irritable outbursts and lack of spontaneity, the 61. Answer: (A) Regression 67. Answer: (D) Rearrange the environment to
esteem, poor concentration, difficulty making client is usually cooperative and exhibits socially Rationale: An adult who throws temper activate the child
decisions, and hopelessness. These symptoms appropriate behavior. Signs of advancement to tantrums, such as this one, is displaying Rationale: The child with autistic disorder does
may be relatively continuous or separated by the middle stage of Alzheimer's disease include regressive behavior, or behavior that is not want change. Maintaining a consistent
intervening periods of normal mood that last a exacerbated cognitive impairment with obvious appropriate at a younger age. In projection, the environment is therapeutic. A. Angry outburst
few days to a few weeks. Cyclothymic disorder is personality changes and impaired client blames someone or something other than can be re-channeling through safe activities. B.
a chronic mood disturbance of at least 2 years' communication, such as inappropriate the source. In reaction formation, the client acts Acceptance enhances a trusting relationship. C.
duration marked by numerous periods of conversation, actions, and responses. During the in opposition to his feelings. In Ensure safety from self-destructive behaviors
depression and hypomania. Atypical affective late stage, the client can't perform self-care intellectualization, the client overuses rational like head banging and hair pulling.
disorder is characterized by manic signs and activities and may become mute. explanations or abstract thinking to decrease the 68. Answer: (B) cocaine
symptoms. Major depression is a recurring, 58. Answer: (D) This medication may initially cause significance of a feeling or event. Rationale: The manifestations indicate
persistent sadness or loss of interest or pleasure tiredness, which should become less 62. Answer: (A) Abnormal movements and intoxication with cocaine, a CNS stimulant. A.
in almost all activities, with signs and symptoms bothersome over time. involuntary movements of the mouth, tongue, Intoxication with heroine is manifested by
recurring for at least 2 weeks. Rationale: Sedation is a common early adverse and face. euphoria then impairment in judgment,
53. Answer: (C) 30 g mixed in 250 ml of water effect of imipramine, a tricyclic antidepressant, Rationale: Tardive dyskinesia is a severe reaction attention and the presence of papillary
Rationale: The usual adult dosage of activated and usually decreases as tolerance develops. associated with long term use of antipsychotic constriction. C. Intoxication with hallucinogen
charcoal is 5 to 10 times the estimated weight of Antidepressants aren't habit forming and don't medication. The clinical manifestations include like LSD is manifested by grandiosity,
the drug or chemical ingested, or a minimum cause physical or psychological dependence. abnormal movements (dyskinesia) and hallucinations, synesthesia and increase in vital
dose of 30 g, mixed in 250 ml of water. Doses However, after a long course of high-dose involuntary movements of the mouth, tongue signs D. Intoxication with Marijuana, a
less than this will be ineffective; doses greater therapy, the dosage should be decreased (fly catcher tongue), and face. cannabinoid is manifested by sensation of
than this can increase the risk of adverse gradually to avoid mild withdrawal symptoms. 63. Answer: (C) Blurred vision slowed time, conjunctival redness, social
reactions, although toxicity doesn't occur with Serious adverse effects, although rare, include Rationale: At lithium levels of 2 to 2.5 mEq/L the withdrawal, impaired judgment and
activated charcoal, even at the maximum dose. myocardial infarction, heart failure, and client will experienced blurred vision, muscle hallucinations.
54. Answer: (C) St. John's wort tachycardia. Dietary restrictions, such as twitching, severe hypotension, and persistent 69. Answer: (B) insidious onset
Rationale: St. John's wort has been found to avoiding aged cheeses, yogurt, and chicken nausea and vomiting. With levels between 1.5 Rationale: Dementia has a gradual onset and
have serotonin-elevating properties, similar to livers, are necessary for a client taking a and 2 mEq/L the client experiencing vomiting, progressive deterioration. It causes pronounced
prescription antidepressants. Ginkgo biloba is monoamine oxidase inhibitor, not a tricyclic diarrhea, muscle weakness, ataxia, dizziness, memory and cognitive disturbances. A,C and D
prescribed to enhance mental acuity. Echinacea antidepressant. slurred speech, and confusion. At lithium levels are all characteristics of delirium.
has immune-stimulating properties. Ephedra is a 59. Answer: (C) Monitor vital signs, serum of 2.5 to 3 mEq/L or higher, urinary and fecal 70. Answer: (C) Claustrophobia
naturally occurring stimulant that is similar to electrolyte levels, and acid-base balance. incontinence occurs, as well as seizures, cardiac Rationale: Claustrophobia is fear of closed space.
ephedrine. Rationale: An anorexic client who requires dysrythmias, peripheral vascular collapse, and A. Agoraphobia is fear of open space or being a
55. Answer: (B) Sodium hospitalization is in poor physical condition from death. situation where escape is difficult. B. Social
Rationale: Lithium is chemically similar to starvation and may die as a result of 64. Answer: (C) No acts of aggression have been phobia is fear of performing in the presence of
sodium. If sodium levels are reduced, such as arrhythmias, hypothermia, malnutrition, observed within 1 hour after the release of two others in a way that will be humiliating or
from sweating or diuresis, lithium will be infection, or cardiac abnormalities secondary to of the extremity restraints. embarrassing. D. Xenophobia is fear of
reabsorbed by the kidneys, increasing the risk of electrolyte imbalances. Therefore, monitoring Rationale: The best indicator that the behavior is strangers.
toxicity. Clients taking lithium shouldn't restrict the client's vital signs, serum electrolyte level, controlled, if the client exhibits no signs of 71. Answer: (A) Revealing personal information to
their intake of sodium and should drink and acid base balance is crucial. Option A may aggression after partial release of restraints. the client
adequate amounts of fluid each day. The other worsen anxiety. Option B is incorrect because a Options , B, and D do not ensure that the client Rationale: Counter-transference is an emotional
electrolytes are important for normal body weight obtained after breakfast is more accurate has controlled the behavior. reaction of the nurse on the client based on her
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unconscious needs and conflicts. B and C. These Rationale: The DSM-IV-TR classifies major Rationale: Secondary gain refers to the benefits from moderate depression to hypomania.
are therapeutic approaches. D. This is depression as an Axis I disorder. Borderline of the illness that allow the client to receive Bipolar I disorder is characterized by a single
transference reaction where a client has an personality disorder as an Axis II; obesity and emotional support or attention. Primary gain manic episode with no past major depressive
emotional reaction towards the nurse based on hypertension, Axis III. enables the client to avoid some unpleasant episodes. Seasonal- affective disorder is a form
her past. 77. Answer: (B) Transference activity. A dysfunctional family may disregard of depression occurring in the fall and winter.
72. Answer: (D) Hold the next dose and obtain an Rationale: Transference is the unconscious the real issue, although some conflict is relieved. 87. Answer: (A) Vascular dementia has more abrupt
order for a stat serum lithium level assignment of negative or positive feelings Somatoform pain disorder is a preoccupation onset
Rationale: Diarrhea and vomiting are evoked by a significant person in the client’s past with pain in the absence of physical disease. Rationale: Vascular dementia differs from
manifestations of Lithium toxicity. The next dose to another person. Intellectualization is a 82. Answer: (A) “I went to the mall with my friends Alzheimer’s disease in that it has a more abrupt
of lithium should be withheld and test is done to defense mechanism in which the client avoids last Saturday” onset and runs a highly variable course.
validate the observation. A. The manifestations dealing with emotions by focusing on facts. Rationale: Clients with panic disorder tent to be Personally change is common in Alzheimer’s
are not due to drug interaction. B. Cogentin is Triangulation refers to conflicts involving three socially withdrawn. Going to the mall is a sign of disease. The duration of delirium is usually brief.
used to manage the extra pyramidal symptom family members. Splitting is a defense working on avoidance behaviors. The inability to carry out motor activities is
side effects of antipsychotics. C. The common mechanism commonly seen in clients with Hyperventilating is a key symptom of panic common in Alzheimer’s disease.
side effects of Lithium are fine hand tremors, personality disorder in which the world is disorder. Teaching breathing control is a major 88. Answer: (C) Drug intoxication
nausea, polyuria and polydipsia. perceived as all good or all bad. intervention for clients with panic disorder. The Rationale: This client was taking several
73. Answer: (C) A living, learning or working 78. Answer: (B) Hypochondriasis client taking medications for panic disorder; such medications that have a propensity for
environment. Rationale: Complains of vague physical as tricylic antidepressants and benzodiazepines producing delirium; digoxin (a digitalis
Rationale: A therapeutic milieu refers to a broad symptoms that have no apparent medical causes must be weaned off these drugs. Most clients glycoxide), furosemide (a thiazide diuretic), and
conceptual approach in which all aspects of the are characteristic of clients with with panic disorder with agoraphobia don’t have diazepam (a benzodiazepine). Sufficient
environment are channeled to provide a hypochondriasis. In many cases, the GI system is nutritional problems. supporting data don’t exist to suspect the other
therapeutic environment for the client. The six affected. Conversion disorders are characterized 83. Answer: (A) “I’m sleeping better and don’t have options as causes.
environmental elements include structure, by one or more neurologic symptoms. The nightmares” 89. Answer: (D) The client is experiencing visual
safety, norms; limit setting, balance and unit client’s symptoms don’t suggest severe anxiety. Rationale: MAO inhibitors are used to treat sleep hallucination
modification. A. Behavioral approach in A client experiencing sublimation channels problems, nightmares, and intrusive daytime Rationale: The presence of a sensory stimulus
psychiatric care is based on the premise that maladaptive feelings or impulses into socially thoughts in individual with posttraumatic stress correlates with the definition of a hallucination,
behavior can be learned or unlearned through acceptable behavior disorder. MAO inhibitors aren’t used to help which is a false sensory perception. Aphasia
the use of reward and punishment. B. Cognitive 79. Answer: (C) Hypochondriasis control flashbacks or phobias or to decrease the refers to a communication problem. Dysarthria is
approach to change behavior is done by Rationale: Hypochodriasis in this case is shown craving for alcohol. difficulty in speech production. Flight of ideas is
correcting distorted perceptions and irrational by the client’s belief that she has a serious 84. Answer: (D) Stopping the drug can cause rapid shifting from one topic to another.
beliefs to correct maladaptive behaviors. D. This illness, although pathologic causes have been withdrawal symptoms 90. Answer: (D) The client looks at the shadow on a
is not congruent with therapeutic milieu. eliminated. The disturbance usually lasts at least Rationale: Stopping antianxiety drugs such as wall and tells the nurse she sees frightening
74. Answer: (B) Transference 6 with identifiable life stressor such as, in this benzodiazepines can cause the client to have faces on the wall.
Rationale: Transference is a positive or negative case, course examinations. Conversion disorders withdrawal symptoms. Stopping a Rationale: Minor memory problems are
feeling associated with a significant person in are characterized by one or more neurologic benzodiazepine doesn’t tend to cause distinguished from dementia by their minor
the client’s past that are unconsciously assigned symptoms. Depersonalization refers to depression, increase cognitive abilities, or severity and their lack of significant interference
to another A. Splitting is a defense mechanism persistent recurrent episodes of feeling decrease sleeping difficulties. with the client’s social or occupational lifestyle.
commonly seen in a client with personality detached from one’s self or body. Somatoform 85. Answer: (B) Behavioral difficulties Other options would be included in the history
disorder in which the world is perceived as all disorders generally have a chronic course with Rationale: Adolescents tend to demonstrate data but don’t directly correlate with the client’s
good or all bad C. Countert-transference is a few remissions. severe irritability and behavioral problems lifestyle.
phenomenon where the nurse shifts feelings 80. Answer: (A) Triazolam (Halcion) rather than simply a depressed mood. Anxiety 91. Answer: (D) Loose association
assigned to someone in her past to the patient Rationale: Triazolam is one of a group of disorder is more commonly associated with Rationale: Loose associations are conversations
D. Resistance is the client’s refusal to submit sedative hypnotic medication that can be used small children rather than with adolescents. that constantly shift in topic. Concrete thinking
himself to the care of the nurse for a limited time because of the risk of Cognitive impairment is typically associated with implies highly definitive thought processes.
75. Answer: (B) Adventitious dependence. Paroxetine is a scrotonin-specific delirium or dementia. Labile mood is more Flight of ideas is characterized by conversation
Rationale: Adventitious crisis is a crisis involving reutake inhibitor used for treatment of characteristic of a client with cognitive that’s disorganized from the onset. Loose
a traumatic event. It is not part of everyday life. depression panic disorder, and obsessive- impairment or bipolar disorder. associations don’t necessarily start in a cogently,
A. Situational crisis is from an external source compulsive disorder. Fluoxetine is a scrotonin- 86. Answer: (D) It’s a mood disorder similar to major then becomes loose.
that upset ones psychological equilibrium C and specific reuptake inhibitor used for depressive depression but of mild to moderate severity 92. Answer: (C) Paranoid
D. are the same. They are transitional or disorders and obsessive-compulsive disorders. Rationale: Dysthymic disorder is a mood disorder Rationale: Because of their suspiciousness,
developmental periods in life Risperidome is indicated for psychotic disorders. similar to major depression but it remains mild paranoid personalities ascribe malevolent
76. Answer: (C) Major depression 81. Answer: (D) It promotes emotional support or to moderate in severity. Cyclothymic disorder is activities to others and tent to be defensive,
attention for the client a mood disorder characterized by a mood range becoming quarrelsome and argumentative.
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Clients with antisocial personality disorder can 97. Answer: (B) Echopraxia PART III d. Colostomy irrigation
also be antagonistic and argumentative but are Rationale: Echopraxia is the copying of another’s
less suspicious than paranoid personalities. behaviors and is the result of the loss of ego 7. Sterile technique is used whenever:
Clients with histrionic personality disorder are boundaries. Modeling is the conscious copying PRACTICE TEST I FOUNDATION OF NURSING a. Strict isolation is required
dramatic, not suspicious and argumentative. of someone’s behaviors. Ego-syntonicity refers b. Terminal disinfection is performed
Clients with schizoid personality disorder are to behaviors that correspond with the 1. Which element in the circular chain of infection c. Invasive procedures are performed
usually detached from other and tend to have individual’s sense of self. Ritualism behaviors are can be eliminated by preserving skin integrity? d. Protective isolation is necessary
eccentric behavior. repetitive and compulsive. a. Host
93. Answer: (C) Explain that the drug is less affective 98. Answer: (C) Hallucination b. Reservoir 8. Which of the following constitutes a break in
if the client smokes Rationale: Hallucinations are sensory c. Mode of transmission sterile technique while preparing a sterile field
Rationale: Olanzapine (Zyprexa) is less effective experiences that are misrepresentations of d. Portal of entry for a dressing change?
for clients who smoke cigarettes. Serotonin reality or have no basis in reality. Delusions are a. Using sterile forceps, rather than sterile
syndrome occurs with clients who take a beliefs not based in reality. Disorganized speech 2. Which of the following will probably result in a gloves, to handle a sterile item
combination of antidepressant medications. is characterized by jumping from one topic to break in sterile technique for respiratory b. Touching the outside wrapper of
Olanzapine doesn’t cause euphoria, and the next or using unrelated words. An idea of isolation? sterilized material without sterile gloves
extrapyramidal adverse reactions aren’t a reference is a belief that an unrelated situation a. Opening the patient’s window to the c. Placing a sterile object on the edge of
problem. However, the client should be aware of holds special meaning for the client. outside environment the sterile field
adverse effects such as tardive dyskinesia. 99. Answer: (C) Regression b. Turning on the patient’s room ventilator d. Pouring out a small amount of solution
94. Answer: (A) Lack of honesty Rationale: Regression, a return to earlier c. Opening the door of the patient’s room (15 to 30 ml) before pouring the solution
Rationale: Clients with antisocial personality behavior to reduce anxiety, is the basic defense leading into the hospital corridor into a sterile container
disorder tent to engage in acts of dishonesty, mechanism in schizophrenia. Projection is a d. Failing to wear gloves when 9. A natural body defense that plays an active role
shown by lying. Clients with schizotypal defense mechanism in which one blames others administering a bed bath in preventing infection is:
personality disorder tend to be superstitious. and attempts to justify actions; it’s used a. Yawning
Clients with histrionic personality disorders tend primarily by people with paranoid schizophrenia 3. Which of the following patients is at greater risk b. Body hair
to overreact to frustrations and and delusional disorder. Rationalization is a for contracting an infection? c. Hiccupping
disappointments, have temper tantrums, and defense mechanism used to justify one’s action. a. A patient with leukopenia d. Rapid eye movements
seek attention. Repression is the basic defense mechanism in b. A patient receiving broad-spectrum
95. Answer: (A) “I’m not going to look just at the the neuroses; it’s an involuntary exclusion of antibiotics 10. All of the following statement are true about
negative things about myself” painful thoughts, feelings, or experiences from c. A postoperative patient who has donning sterile gloves except:
Rationale: As the client makes progress on awareness. undergone orthopedic surgery a. The first glove should be picked up by
improving self-esteem, self- blame and negative 100. Answer: (A) Should report feelings of d. A newly diagnosed diabetic patient grasping the inside of the cuff.
self-evaluation will decrease. Clients with restlessness or agitation at once b. The second glove should be picked up by
dependent personality disorder tend to feel Rationale: Agitation and restlessness are adverse 4. Effective hand washing requires the use of: inserting the gloved fingers under the
fragile and inadequate and would be extremely effect of haloperidol and can be treated with a. Soap or detergent to promote cuff outside the glove.
unlikely to discuss their level of competence and antocholinergic drugs. Haloperidol isn’t likely to emulsification c. The gloves should be adjusted by sliding
progress. These clients focus on self and aren’t cause photosensitivity or control essential b. Hot water to destroy bacteria the gloved fingers under the sterile cuff
envious or jealous. Individuals with dependent hypertension. Although the client may c. A disinfectant to increase surface and pulling the glove over the wrist
personality disorders don’t take over situations experience increased concentration and activity, tension d. The inside of the glove is considered
because they see themselves as inept and these effects are due to a decreased in d. All of the above sterile
inadequate. symptoms, not the drug itself.
96. Answer: (C) Assess for possible physical 5. After routine patient contact, hand washing 11. When removing a contaminated gown, the nurse
problems such as rash should last at least: should be careful that the first thing she touches
Rationale: Clients with schizophrenia generally a. 30 seconds is the:
have poor visceral recognition because they live b. 1 minute a. Waist tie and neck tie at the back of the
so fully in their fantasy world. They need to have c. 2 minute gown
as in-depth assessment of physical complaints d. 3 minutes b. Waist tie in front of the gown
that may spill over into their delusional c. Cuffs of the gown
symptoms. Talking with the client won’t provide 6. Which of the following procedures always d. Inside of the gown
as assessment of his itching, and itching isn’t as requires surgical asepsis?
adverse reaction of antipsychotic drugs, calling a. Vaginal instillation of conjugated 12. Which of the following nursing interventions is
the physician to get the client’s medication estrogen considered the most effective form or universal
increased doesn’t address his physical b. Urinary catheterization precautions?
complaints. c. Nasogastric tube insertion
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a. Cap all used needles before removing b. Before the procedure, the patient should 23. The mid-deltoid injection site is seldom used for a. Fever
them from their syringes remove all jewelry, metallic objects, and I.M. injections because it: b. Chronic Obstructive Pulmonary Disease
b. Discard all used uncapped needles and buttons above the waist a. Can accommodate only 1 ml or less of c. Renal Failure
syringes in an impenetrable protective c. A signed consent is not required medication d. Dehydration
container d. Eating, drinking, and medications are b. Bruises too easily
c. Wear gloves when administering IM allowed before this test c. Can be used only when the patient is 31. All of the following are common signs and
injections lying down symptoms of phlebitis except:
d. Follow enteric precautions 19. The most appropriate time for the nurse to d. Does not readily parenteral medication a. Pain or discomfort at the IV insertion site
obtain a sputum specimen for culture is: b. Edema and warmth at the IV insertion
13. All of the following measures are recommended a. Early in the morning 24. The appropriate needle size for insulin injection site
to prevent pressure ulcers except: b. After the patient eats a light breakfast is: c. A red streak exiting the IV insertion site
a. Massaging the reddened are with lotion c. After aerosol therapy a. 18G, 1 ½” long d. Frank bleeding at the insertion site
b. Using a water or air mattress d. After chest physiotherapy b. 22G, 1” long
c. Adhering to a schedule for positioning c. 22G, 1 ½” long 32. The best way of determining whether a patient
and turning 20. A patient with no known allergies is to receive d. 25G, 5/8” long has learned to instill ear medication properly is
d. Providing meticulous skin care penicillin every 6 hours. When administering the for the nurse to:
medication, the nurse observes a fine rash on 25. The appropriate needle gauge for intradermal a. Ask the patient if he/she has used ear
14. Which of the following blood tests should be the patient’s skin. The most appropriate nursing injection is: drops before
performed before a blood transfusion? action would be to: a. 20G b. Have the patient repeat the nurse’s
a. Prothrombin and coagulation time a. Withhold the moderation and notify the b. 22G instructions using her own words
b. Blood typing and cross-matching physician c. 25G c. Demonstrate the procedure to the
c. Bleeding and clotting time b. Administer the medication and notify d. 26G patient and encourage to ask questions
d. Complete blood count (CBC) and the physician d. Ask the patient to demonstrate the
electrolyte levels. c. Administer the medication with an 26. Parenteral penicillin can be administered as an: procedure
antihistamine a. IM injection or an IV solution
15. The primary purpose of a platelet count is to d. Apply corn starch soaks to the rash b. IV or an intradermal injection 33. Which of the following types of medications can
evaluate the: c. Intradermal or subcutaneous injection be administered via gastrostomy tube?
a. Potential for clot formation 21. All of the following nursing interventions are d. IM or a subcutaneous injection a. Any oral medications
b. Potential for bleeding correct when using the Z- track method of drug b. Capsules whole contents are dissolve in
c. Presence of an antigen-antibody injection except: 27. The physician orders gr 10 of aspirin for a water
response a. Prepare the injection site with alcohol patient. The equivalent dose in milligrams is: c. Enteric-coated tablets that are
d. Presence of cardiac enzymes b. Use a needle that’s a least 1” long a. 0.6 mg thoroughly dissolved in water
c. Aspirate for blood before injection b. 10 mg d. Most tablets designed for oral use,
16. Which of the following white blood cell (WBC) d. Rub the site vigorously after the c. 60 mg except for extended-duration
counts clearly indicates leukocytosis? injection to promote absorption d. 600 mg compounds
a. 4,500/mm³
b. 7,000/mm³ 22. The correct method for determining the vastus 28. The physician orders an IV solution of dextrose 34. A patient who develops hives after receiving an
c. 10,000/mm³ lateralis site for I.M. injection is to: 5% in water at 100ml/hour. What would the antibiotic is exhibiting drug:
d. 25,000/mm³ a. Locate the upper aspect of the upper flow rate be if the drop factor is 15 gtt = 1 ml? a. Tolerance
outer quadrant of the buttock about 5 to a. 5 gtt/minute b. Idiosyncrasy
17. After 5 days of diuretic therapy with 20mg of 8 cm below the iliac crest b. 13 gtt/minute c. Synergism
furosemide (Lasix) daily, a patient begins to b. Palpate the lower edge of the acromion c. 25 gtt/minute d. Allergy
exhibit fatigue, muscle cramping and muscle process and the midpoint lateral aspect d. 50 gtt/minute
weakness. These symptoms probably indicate of the arm 35. A patient has returned to his room after femoral
that the patient is experiencing: c. Palpate a 1” circular area anterior to the 29. Which of the following is a sign or symptom of a arteriography. All of the following are
a. Hypokalemia umbilicus hemolytic reaction to blood transfusion? appropriate nursing interventions except:
b. Hyperkalemia d. Divide the area between the greater a. Hemoglobinuria a. Assess femoral, popliteal, and pedal
c. Anorexia femoral trochanter and the lateral b. Chest pain pulses every 15 minutes for 2 hours
d. Dysphagia femoral condyle into thirds, and select c. Urticaria b. Check the pressure dressing for
the middle third on the anterior of the d. Distended neck veins sanguineous drainage
18. Which of the following statements about chest thigh c. Assess vital signs every 15 minutes for 2
X-ray is false? 30. Which of the following conditions may require hours
a. No contradictions exist for this test fluid restriction?
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d. Order a hemoglobin and hematocrit 42. All of the following are good sources of vitamin A b. Back muscles
count 1 hour after the arteriography except: c. Leg muscles
a. White potatoes d. Upper arm muscles
36. The nurse explains to a patient that a cough: b. Carrots
a. Is a protective response to clear the c. Apricots 48. Thrombophlebitis typically develops in patients
respiratory tract of irritants d. Egg yolks with which of the following conditions?
b. Is primarily a voluntary action a. Increases partial thromboplastin time
c. Is induced by the administration of an 43. Which of the following is a primary nursing b. Acute pulsus paradoxus
antitussive drug intervention necessary for all patients with a c. An impaired or traumatized blood vessel
d. Can be inhibited by “splinting” the Foley Catheter in place? wall
abdomen a. Maintain the drainage tubing and d. Chronic Obstructive Pulmonary Disease
collection bag level with the patient’s (COPD)
37. An infected patient has chills and begins bladder
shivering. The best nursing intervention is to: b. Irrigate the patient with 1% Neosporin 49. In a recumbent, immobilized patient, lung
a. Apply iced alcohol sponges solution three times a daily ventilation can become altered, leading to such
b. Provide increased cool liquids c. Clamp the catheter for 1 hour every 4 respiratory complications as:
c. Provide additional bedclothes hours to maintain the bladder’s elasticity a. Respiratory acidosis, ateclectasis, and
d. Provide increased ventilation d. Maintain the drainage tubing and hypostatic pneumonia
collection bag below bladder level to b. Appneustic breathing, atypical
38. A clinical nurse specialist is a nurse who has: facilitate drainage by gravity pneumonia and respiratory alkalosis
a. Been certified by the National League for c. Cheyne-Strokes respirations and
Nursing 44. The ELISA test is used to: spontaneous pneumothorax
b. Received credentials from the Philippine a. Screen blood donors for antibodies to d. Kussmail’s respirations and
Nurses’ Association human immunodeficiency virus (HIV) hypoventilation
c. Graduated from an associate degree b. Test blood to be used for transfusion for
program and is a registered professional HIV antibodies 50. Immobility impairs bladder elimination, resulting
nurse c. Aid in diagnosing a patient with AIDS in such disorders as
d. Completed a master’s degree in the d. All of the above a. Increased urine acidity and relaxation of
prescribed clinical area and is a the perineal muscles, causing
registered professional nurse. 45. The two blood vessels most commonly used for incontinence
TPN infusion are the: b. Urine retention, bladder distention, and
39. The purpose of increasing urine acidity through a. Subclavian and jugular veins infection
dietary means is to: b. Brachial and subclavian veins c. Diuresis, natriuresis, and decreased
a. Decrease burning sensations c. Femoral and subclavian veins urine specific gravity
b. Change the urine’s color d. Brachial and femoral veins d. Decreased calcium and phosphate levels
c. Change the urine’s concentration in the urine
d. Inhibit the growth of microorganisms 46. Effective skin disinfection before a surgical
procedure includes which of the following
40. Clay colored stools indicate: methods?
a. Upper GI bleeding a. Shaving the site on the day before
b. Impending constipation surgery
c. An effect of medication b. Applying a topical antiseptic to the skin
d. Bile obstruction on the evening before surgery
c. Having the patient take a tub bath on
41. In which step of the nursing process would the the morning of surgery
nurse ask a patient if the medication she d. Having the patient shower with an
administered relieved his pain? antiseptic soap on the evening v=before
a. Assessment and the morning of surgery
b. Analysis
c. Planning 47. When transferring a patient from a bed to a
d. Evaluation chair, the nurse should use which muscles to
avoid back injury?
a. Abdominal muscles
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ANSWERS AND RATIONALE – FOUNDATION OF to prepare them for reuse by another patient. 15. A. Platelets are disk-shaped cells that are 21. D. The Z-track method is an I.M. injection
NURSING The purpose of protective (reverse) isolation is essential for blood coagulation. A platelet count technique in which the patient’s skin is pulled in
to prevent a person with seriously impaired determines the number of thrombocytes in such a way that the needle track is sealed off
1. D. In the circular chain of infection, pathogens resistance from coming into contact who blood available for promoting hemostasis and after the injection. This procedure seals
must be able to leave their reservoir and be potentially pathogenic organisms. assisting with blood coagulation after injury. It medication deep into the muscle, thereby
transmitted to a susceptible host through a 8. C. The edges of a sterile field are considered also is used to evaluate the patient’s potential minimizing skin staining and irritation. Rubbing
portal of entry, such as broken skin. contaminated. When sterile items are allowed to for bleeding; however, this is not its primary the injection site is contraindicated because it
2. C. Respiratory isolation, like strict isolation, come in contact with the edges of the field, the purpose. The normal count ranges from 150,000 may cause the medication to extravasate into
requires that the door to the door patient’s sterile items also become contaminated. to 350,000/mm3. A count of 100,000/mm3 or the skin.
room remain closed. However, the patient’s 9. B. Hair on or within body areas, such as the less indicates a potential for bleeding; count of 22. D. The vastus lateralis, a long, thick muscle that
room should be well ventilated, so opening the nose, traps and holds particles that contain less than 20,000/mm3 is associated with extends the full length of the thigh, is viewed by
window or turning on the ventricular is microorganisms. Yawning and hiccupping do not spontaneous bleeding. many clinicians as the site of choice for I.M.
desirable. The nurse does not need to wear prevent microorganisms from entering or 16. D. Leukocytosis is any transient increase in the injections because it has relatively few major
gloves for respiratory isolation, but good hand leaving the body. Rapid eye movement marks number of white blood cells (leukocytes) in the nerves and blood vessels. The middle third of the
washing is important for all types of isolation. the stage of sleep during which dreaming occurs. blood. Normal WBC counts range from 5,000 to muscle is recommended as the injection site.
3. A. Leukopenia is a decreased number of 10. D. The inside of the glove is always considered to 100,000/mm3. Thus, a count of 25,000/mm3 The patient can be in a supine or sitting position
leukocytes (white blood cells), which are be clean, but not sterile. indicates leukocytosis. for an injection into this site.
important in resisting infection. None of the 11. A. The back of the gown is considered clean, the 17. A. Fatigue, muscle cramping, and muscle 23. A. The mid-deltoid injection site can
other situations would put the patient at risk for front is contaminated. So, after removing gloves weaknesses are symptoms of hypokalemia (an accommodate only 1 ml or less of medication
contracting an infection; taking broad- spectrum and washing hands, the nurse should untie the inadequate potassium level), which is a potential because of its size and location (on the deltoid
antibiotics might actually reduce the infection back of the gown; slowly move backward away side effect of diuretic therapy. The physician muscle of the arm, close to the brachial artery
risk. from the gown, holding the inside of the gown usually orders supplemental potassium to and radial nerve).
4. A. Soaps and detergents are used to help and keeping the edges off the floor; turn and prevent hypokalemia in patients receiving 24. D. A 25G, 5/8” needle is the recommended size
remove bacteria because of their ability to lower fold the gown inside out; discard it in a diuretics. Anorexia is another symptom of for insulin injection because insulin is
the surface tension of water and act as contaminated linen container; then wash her hypokalemia. Dysphagia means difficulty administered by the subcutaneous route. An
emulsifying agents. Hot water may lead to skin hands again. swallowing. 18G, 1 ½” needle is usually used for I.M.
irritation or burns. 12. B. According to the Centers for Disease Control 18. A. Pregnancy or suspected pregnancy is the only injections in children, typically in the vastus
5. A. Depending on the degree of exposure to (CDC), blood-to-blood contact occurs most contraindication for a chest X-ray. However, if a lateralis. A 22G, 1 ½” needle is usually used for
pathogens, hand washing may last from 10 commonly when a health care worker attempts chest X-ray is necessary, the patient can wear a adult I.M. injections, which are typically
seconds to 4 minutes. After routine patient to cap a used needle. Therefore, used needles lead apron to protect the pelvic region from administered in the vastus lateralis or
contact, hand washing for 30 seconds effectively should never be recapped; instead they should radiation. Jewelry, metallic objects, and buttons ventrogluteal site.
minimizes the risk of pathogen transmission. be inserted in a specially designed puncture would interfere with the X-ray and thus should 25. D. Because an intradermal injection does not
6. B. The urinary system is normally free of resistant, labeled container. Wearing gloves is not be worn above the waist. A signed consent is penetrate deeply into the skin, a small-bore 25G
microorganisms except at the urinary meatus. not always necessary when administering an I.M. not required because a chest X-ray is not an needle is recommended. This type of injection is
Any procedure that involves entering this system injection. Enteric precautions prevent the invasive examination. Eating, drinking and used primarily to administer antigens to
must use surgically aseptic measures to maintain transfer of pathogens via feces. medications are allowed because the X-ray is of evaluate reactions for allergy or sensitivity
a bacteria-free state. 13. A. Nurses and other health care professionals the chest, not the abdominal region. studies. A 20G needle is usually used for I.M.
7. C. All invasive procedures, including surgery, previously believed that massaging a reddened 19. A. Obtaining a sputum specimen early in this injections of oil- based medications; a 22G
catheter insertion, and administration of area with lotion would promote venous return morning ensures an adequate supply of bacteria needle for I.M. injections; and a 25G needle, for
parenteral therapy, require sterile technique to and reduce edema to the area. However, for culturing and decreases the risk of I.M. injections; and a 25G needle, for
maintain a sterile environment. All equipment research has shown that massage only increases contamination from food or medication. subcutaneous insulin injections.
must be sterile, and the nurse and the physician the likelihood of cellular ischemia and necrosis 20. A. Initial sensitivity to penicillin is commonly 26. A. Parenteral penicillin can be administered I.M.
must wear sterile gloves and maintain surgical to the area. manifested by a skin rash, even in individuals or added to a solution and given I.V. It cannot be
asepsis. In the operating room, the nurse and 14. B. Before a blood transfusion is performed, the who have not been allergic to it previously. administered subcutaneously or intradermally.
physician are required to wear sterile gowns, blood of the donor and recipient must be Because of the danger of anaphylactic shock, he 27. D. gr 10 x 60mg/gr 1 = 600 mg
gloves, masks, hair covers, and shoe covers for checked for compatibility. This is done by blood nurse should withhold the drug and notify the 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
all invasive procedures. Strict isolation requires typing (a test that determines a person’s blood physician, who may choose to substitute 29. A. Hemoglobinuria, the abnormal presence of
the use of clean gloves, masks, gowns and type) and cross-matching (a procedure that another drug. Administering an antihistamine is hemoglobin in the urine, indicates a hemolytic
equipment to prevent the transmission of highly determines the compatibility of the donor’s and a dependent nursing intervention that requires a reaction (incompatibility of the donor’s and
communicable diseases by contact or by recipient’s blood after the blood types has been written physician’s order. Although applying recipient’s blood). In this reaction, antibodies in
airborne routes. Terminal disinfection is the matched). If the blood specimens are corn starch to the rash may relieve discomfort, it the recipient’s plasma combine rapidly with
disinfection of all contaminated supplies and incompatible, hemolysis and antigen-antibody is not the nurse’s top priority in such a donor RBC’s; the cells are hemolyzed in either
equipment after a patient has been discharged reactions will occur. potentially life-threatening situation. circulatory or reticuloendothelial system.
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Hemolysis occurs more rapidly in ABO 36. A. Coughing, a protective response that clears 42. A. The main sources of vitamin A are yellow and not necessarily impede venous return of injure
incompatibilities than in Rh incompatibilities. the respiratory tract of irritants, usually is green vegetables (such as carrots, sweet vessel walls.
Chest pain and urticarial may be symptoms of involuntary; however it can be voluntary, as potatoes, squash, spinach, collard greens, 49. A. Because of restricted respiratory movement, a
impending anaphylaxis. Distended neck veins are when a patient is taught to perform coughing broccoli, and cabbage) and yellow fruits (such as recumbent, immobilize patient is at particular
an indication of hypervolemia. exercises. An antitussive drug inhibits coughing. apricots, and cantaloupe). Animal sources risk for respiratory acidosis from poor gas
30. C. In real failure, the kidney loses their ability to Splinting the abdomen supports the abdominal include liver, kidneys, cream, butter, and egg exchange; atelectasis from reduced surfactant
effectively eliminate wastes and fluids. Because muscles when a patient coughs. yolks. and accumulated mucus in the bronchioles, and
of this, limiting the patient’s intake of oral and 37. C. In an infected patient, shivering results from 43. D. Maintaing the drainage tubing and collection hypostatic pneumonia from bacterial growth
I.V. fluids may be necessary. Fever, chronic the body’s attempt to increase heat production bag level with the patient’s bladder could result caused by stasis of mucus secretions.
obstructive pulmonary disease, and dehydration and the production of neutrophils and in reflux of urine into the kidney. Irrigating the 50. B. The immobilized patient commonly suffers
are conditions for which fluids should be phagocytotic action through increased skeletal bladder with Neosporin and clamping the from urine retention caused by decreased
encouraged. muscle tension and contractions. Initial catheter for 1 hour every 4 hours must be muscle tone in the perineum. This leads to
31. D. Phlebitis, the inflammation of a vein, can be vasoconstriction may cause skin to feel cold to prescribed by a physician. bladder distention and urine stagnation, which
caused by chemical irritants (I.V. solutions or the touch. Applying additional bed clothes helps 44. D. The ELISA test of venous blood is used to provide an excellent medium for bacterial
medications), mechanical irritants (the needle or to equalize the body temperature and stop the assess blood and potential blood donors to growth leading to infection. Immobility also
catheter used during venipuncture or chills. Attempts to cool the body result in further human immunodeficiency virus (HIV). A positive results in more alkaline urine with excessive
cannulation), or a localized allergic reaction to shivering, increased metabloism, and thus ELISA test combined with various signs and amounts of calcium, sodium and phosphate, a
the needle or catheter. Signs and symptoms of increased heat production. symptoms helps to diagnose acquired gradual decrease in urine production, and an
phlebitis include pain or discomfort, edema and 38. D. A clinical nurse specialist must have immunodeficiency syndrome (AIDS) increased specific gravity.
heat at the I.V. insertion site, and a red streak completed a master’s degree in a clinical 45. D. Tachypnea (an abnormally rapid rate of
going up the arm or leg from the I.V. insertion specialty and be a registered professional nurse. breathing) would indicate that the patient was
site. The National League of Nursing accredits still hypoxic (deficient in oxygen).The partial
32. D. Return demonstration provides the most educational programs in nursing and provides a pressures of arterial oxygen and carbon dioxide
certain evidence for evaluating the effectiveness testing service to evaluate student nursing listed are within the normal range. Eupnea refers
of patient teaching. competence but it does not certify nurses. The to normal respiration.
33. D. Capsules, enteric-coated tablets, and most American Nurses Association identifies 46. D. Studies have shown that showering with an
extended duration or sustained release products requirements for certification and offers antiseptic soap before surgery is the most
should not be dissolved for use in a gastrostomy examinations for certification in many areas of effective method of removing microorganisms
tube. They are pharmaceutically manufactured nursing, such as medical surgical nursing. These from the skin. Shaving the site of the intended
in these forms for valid reasons, and altering certification (credentialing) demonstrates that surgery might cause breaks in the skin, thereby
them destroys their purpose. The nurse should the nurse has the knowledge and the ability to increasing the risk of infection; however, if
seek an alternate physician’s order when an provide high quality nursing care in the area of indicated, shaving, should be done immediately
ordered medication is inappropriate for delivery her certification. A graduate of an associate before surgery, not the day before. A topical
by tube. degree program is not a clinical nurse specialist: antiseptic would not remove microorganisms
34. D. A drug-allergy is an adverse reaction resulting however, she is prepared to provide bed side and would be beneficial only after proper
from an immunologic response following a nursing with a high degree of knowledge and cleaning and rinsing. Tub bathing might transfer
previous sensitizing exposure to the drug. The skill. She must successfully complete the organisms to another body site rather than rinse
reaction can range from a rash or hives to licensing examination to become a registered them away.
anaphylactic shock. Tolerance to a drug means professional nurse. 47. C. The leg muscles are the strongest muscles in
that the patient experiences a decreasing 39. D. Microorganisms usually do not grow in an the body and should bear the greatest stress
physiologic response to repeated administration acidic environment. when lifting. Muscles of the abdomen, back, and
of the drug in the same dosage. Idiosyncrasy is 40. D. Bile colors the stool brown. Any inflammation upper arms may be easily injured.
an individual’s unique hypersensitivity to a drug, or obstruction that impairs bile flow will affect 48. C. The factors, known as Virchow’s triad,
food, or other substance; it appears to be the stool pigment, yielding light, clay-colored collectively predispose a patient to
genetically determined. Synergism, is a drug stool. Upper GI bleeding results in black or tarry thromboplebitis; impaired venous return to the
interaction in which the sum of the drug’s stool. Constipation is characterized by small, heart, blood hypercoagulability, and injury to a
combined effects is greater than that of their hard masses. Many medications and foods will blood vessel wall. Increased partial
separate effects. discolor stool – for example, drugs containing thromboplastin time indicates a prolonged
35. D. A hemoglobin and hematocrit count would be iron turn stool black.; beets turn stool red. bleeding time during fibrin clot formation,
ordered by the physician if bleeding were 41. D. In the evaluation step of the nursing process, commonly the result of anticoagulant (heparin)
suspected. The other answers are appropriate the nurse must decide whether the patient has therapy. Arterial blood disorders (such as pulsus
nursing interventions for a patient who has achieved the expected outcome that was paradoxus) and lung diseases (such as COPD) do
undergone femoral arteriography. identified in the planning phase.
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PRACTICE TEST II Maternal and Child Health cramping and moderate vaginal bleeding. a. A dark red discharge on a 2-day
7. The client tells the nurse that her last menstrual Speculum examination reveals 2 to 3 cms postpartum client
1. For the client who is using oral contraceptives, period started on January 14 and ended on cervical dilation. The nurse would document b. A pink to brownish discharge on a client
the nurse informs the client about the need to January 20. Using Nagele’s rule, the nurse these findings as which of the following? who is 5 days postpartum
take the pill at the same time each day to determines her EDD to be which of the a. Threatened abortion c. Almost colorless to creamy discharge on
accomplish which of the following? following? b. Imminent abortion a client 2 weeks after delivery
a. Decrease the incidence of nausea a. September 27 c. Complete abortion d. A bright red discharge 5 days after
b. Maintain hormonal levels b. October 21 d. Missed abortion delivery
c. Reduce side effects c. November 7
d. Prevent drug interactions d. December 27 13. Which of the following would be the priority 18. A postpartum client has a temperature of
nursing diagnosis for a client with an ectopic 101.4ºF, with a uterus that is tender when
2. When teaching a client about contraception. 8. When taking an obstetrical history on a pregnant pregnancy? palpated, remains unusually large, and not
Which of the following would the nurse include client who states, “I had a son born at 38 weeks a. Risk for infection descending as normally expected. Which of the
as the most effective method for preventing gestation, a daughter born at 30 weeks gestation b. Pain following should the nurse assess next?
sexually transmitted infections? and I lost a baby at about 8 weeks,” the nurse c. Knowledge Deficit a. Lochia
a. Spermicides should record her obstetrical history as which of d. Anticipatory Grieving b. Breasts
b. Diaphragm the following? c. Incision
c. Condoms a. G2 T2 P0 A0 L2 14. Before assessing the postpartum client’s uterus d. Urine
d. Vasectomy b. G3 T1 P1 A0 L2 for firmness and position in relation to the
c. G3 T2 P0 A0 L2 umbilicus and midline, which of the following 19. Which of the following is the priority focus of
3. When preparing a woman who is 2 days d. G4 T1 P1 A1 L2 should the nurse do first? nursing practice with the current early
postpartum for discharge, recommendations for a. Assess the vital signs postpartum discharge?
which of the following contraceptive methods 9. When preparing to listen to the fetal heart rate b. Administer analgesia a. Promoting comfort and restoration of
would be avoided? at 12 weeks’ gestation, the nurse would use c. Ambulate her in the hall health
a. Diaphragm which of the following? d. Assist her to urinate b. Exploring the emotional status of the
b. Female condom a. Stethoscope placed midline at the family
c. Oral contraceptives umbilicus 15. Which of the following should the nurse do c. Facilitating safe and effective self-and
d. Rhythm method b. Doppler placed midline at the when a primipara who is lactating tells the nurse newborn care
suprapubic region that she has sore nipples? d. Teaching about the importance of family
4. For which of the following clients would the c. Fetoscope placed midway between the a. Tell her to breast feed more frequently planning
nurse expect that an intrauterine device would umbilicus and the xiphoid process b. Administer a narcotic before breast
not be recommended? d. External electronic fetal monitor placed feeding 20. Which of the following actions would be least
a. Woman over age 35 at the umbilicus c. Encourage her to wear a nursing effective in maintaining a neutral thermal
b. Nulliparous woman brassiere environment for the newborn?
c. Promiscuous young adult 10. When developing a plan of care for a client d. Use soap and water to clean the nipples a. Placing infant under radiant warmer
d. Postpartum client newly diagnosed with gestational diabetes, after bathing
which of the following instructions would be the 16. The nurse assesses the vital signs of a client, 4 b. Covering the scale with a warmed
5. A client in her third trimester tells the nurse, priority? hours’ postpartum that are as follows: BP 90/60; blanket prior to weighing
“I’m constipated all the time!” Which of the a. Dietary intake temperature 100.4ºF; pulse 100 weak, thready; c. Placing crib close to nursery window for
following should the nurse recommend? b. Medication R 20 per minute. Which of the following should family viewing
a. Daily enemas c. Exercise the nurse do first? d. Covering the infant’s head with a knit
b. Laxatives d. Glucose monitoring a. Report the temperature to the physician stockinette
c. Increased fiber intake b. Recheck the blood pressure with
d. Decreased fluid intake 11. A client at 24 weeks gestation has gained 6 another cuff 21. A newborn who has an asymmetrical Moro
pounds in 4 weeks. Which of the following would c. Assess the uterus for firmness and reflex response should be further assessed for
6. Which of the following would the nurse use as be the priority when assessing the client? position which of the following?
the basis for the teaching plan when caring for a a. Glucosuria d. Determine the amount of lochia a. Talipes equinovarus
pregnant teenager concerned about gaining too b. Depression b. Fractured clavicle
much weight during pregnancy? c. Hand/face edema 17. The nurse assesses the postpartum vaginal c. Congenital hypothyroidism
a. 10 pounds per trimester d. Dietary intake discharge (lochia) on four clients. Which of the d. Increased intracranial pressure
b. 1 pound per week for 40 weeks following assessments would warrant
c. ½ pound per week for 40 weeks 12. A client 12 weeks’ pregnant come to the notification of the physician?
d. A total gain of 25 to 30 pounds emergency department with abdominal
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22. During the first 4 hours after a male b. 3 ounces 32. When performing a pelvic examination, the understanding that breathing techniques are
circumcision, assessing for which of the c. 4 ounces nurse observes a red swollen area on the right most important in achieving which of the
following is the priority? d. 6 ounces side of the vaginal orifice. The nurse would following?
a. Infection document this as enlargement of which of the a. Eliminate pain and give the expectant
b. Hemorrhage 27. The postterm neonate with meconium-stained following? parents something to do
c. Discomfort amniotic fluid needs care designed to especially a. Clitoris b. Reduce the risk of fetal distress by
d. Dehydration monitor for which of the following? b. Parotid gland increasing uteroplacental perfusion
a. Respiratory problems c. Skene’s gland c. Facilitate relaxation, possibly reducing
23. The mother asks the nurse. “What’s wrong with b. Gastrointestinal problems d. Bartholin’s gland the perception of pain
my son’s breasts? Why are they so enlarged?” c. Integumentary problems d. Eliminate pain so that less analgesia and
Whish of the following would be the best d. Elimination problems 33. To differentiate as a female, the hormonal anesthesia are needed
response by the nurse? stimulation of the embryo that must occur
a. “The breast tissue is inflamed from the 28. When measuring a client’s fundal height, which involves which of the following? 38. After 4 hours of active labor, the nurse notes
trauma experienced with birth” of the following techniques denotes the correct a. Increase in maternal estrogen secretion that the contractions of a primigravida client are
b. “A decrease in material hormones method of measurement used by the nurse? b. Decrease in maternal androgen not strong enough to dilate the cervix. Which of
present before birth causes a. From the xiphoid process to the secretion the following would the nurse anticipate doing?
enlargement,” umbilicus c. Secretion of androgen by the fetal gonad a. Obtaining an order to begin IV oxytocin
c. “You should discuss this with your b. From the symphysis pubis to the xiphoid d. Secretion of estrogen by the fetal gonad infusion
doctor. It could be a malignancy” process b. Administering a light sedative to allow
d. “The tissue has hypertrophied while the c. From the symphysis pubis to the fundus 34. A client at 8 weeks’ gestation calls complaining the patient to rest for several hour
baby was in the uterus” d. From the fundus to the umbilicus of slight nausea in the morning hours. Which of c. Preparing for a cesarean section for
the following client interventions should the failure to progress
24. Immediately after birth the nurse notes the 29. A client with severe preeclampsia is admitted nurse question? d. Increasing the encouragement to the
following on a male newborn: respirations 78; with of BP 160/110, proteinuria, and severe a. Taking 1 teaspoon of bicarbonate of patient when pushing begins
apical hearth rate 160 BPM, nostril flaring; mild pitting edema. Which of the following would be soda in an 8-ounce glass of water
intercostal retractions; and grunting at the end most important to include in the client’s plan of b. Eating a few low-sodium crackers before 39. A multigravida at 38 weeks’ gestation is
of expiration. Which of the following should the care? getting out of bed admitted with painless, bright red bleeding and
nurse do? a. Daily weights c. Avoiding the intake of liquids in the mild contractions every 7 to 10 minutes. Which
a. Call the assessment data to the b. Seizure precautions morning hours of the following assessments should be avoided?
physician’s attention c. Right lateral positioning d. Eating six small meals a day instead of a. Maternal vital sign
b. Start oxygen per nasal cannula at 2 d. Stress reduction thee large meals b. Fetal heart rate
L/min. c. Contraction monitoring
c. Suction the infant’s mouth and nares 30. A postpartum primipara asks the nurse, “When 35. The nurse documents positive ballottement in d. Cervical dilation
d. Recognize this as normal first period of can we have sexual intercourse again?” Which of the client’s prenatal record. The nurse
reactivity the following would be the nurse’s best understands that this indicates which of the 40. Which of the following would be the nurse’s
response? following? most appropriate response to a client who asks
25. The nurse hears a mother telling a friend on the a. “Anytime you both want to.” a. Palpable contractions on the abdomen why she must have a cesarean delivery if she has
telephone about umbilical cord care. Which of b. “As soon as choose a contraceptive b. Passive movement of the unengaged a complete placenta previa?
the following statements by the mother method.” fetus a. “You will have to ask your physician
indicates effective teaching? c. “When the discharge has stopped and c. Fetal kicking felt by the client when he returns.”
a. “Daily soap and water cleansing is best” the incision is healed.” d. Enlargement and softening of the uterus b. “You need a cesarean to prevent
b. ‘Alcohol helps it dry and kills germs” d. “After your 6 weeks examination.” hemorrhage.”
c. “An antibiotic ointment applied daily 36. During a pelvic exam the nurse notes a purple- c. “The placenta is covering most of your
prevents infection” 31. When preparing to administer the vitamin K blue tinge of the cervix. The nurse documents cervix.”
d. “He can have a tub bath each day” injection to a neonate, the nurse would select this as which of the following? d. “The placenta is covering the opening of
which of the following sites as appropriate for a. Braxton-Hicks sign the uterus and blocking your baby.”
26. A newborn weighing 3000 grams and feeding the injection? b. Chadwick’s sign
every 4 hours needs 120 calories/kg of body a. Deltoid muscle c. Goodell’s sign 41. The nurse understands that the fetal head is in
weight every 24 hours for proper growth and b. Anterior femoris muscle d. McDonald’s sign which of the following positions with a face
development. How many ounces of 20 cal/oz c. Vastus lateralis muscle presentation?
formula should this newborn receive at each d. Gluteus maximus muscle 37. During a prenatal class, the nurse explains the a. Completely flexed
feeding to meet nutritional needs? rationale for breathing techniques during b. Completely extended
a. 2 ounces preparation for labor based on the c. Partially extended
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d. Partially flexed b. Nurse-midwifery ANSWERS AND RATIONALE – MATERNAL AND 4. C. An IUD may increase the risk of pelvic
c. Clinical nurse specialist CHILD HEALTH inflammatory disease, especially in women with
42. With a fetus in the left-anterior breech d. Prepared childbirth more than one sexual partner, because of the
presentation, the nurse would expect the fetal increased risk of sexually transmitted infections.
heart rate would be most audible in which of the 48. A client has a midpelvic contracture from a 1. B. Regular timely ingestion of oral contraceptives An UID should not be used if the woman has an
following areas? previous pelvic injury due to a motor vehicle is necessary to maintain hormonal levels of the active or chronic pelvic infection, postpartum
a. Above the maternal umbilicus and to the accident as a teenager. The nurse is aware that drugs to suppress the action of the infection, endometrial hyperplasia or carcinoma,
right of midline this could prevent a fetus from passing through hypothalamus and anterior pituitary leading to or uterine abnormalities. Age is not a factor in
b. In the lower-left maternal abdominal or around which structure during childbirth? inappropriate secretion of FSH and LH. determining the risks associated with IUD use.
quadrant a. Symphysis pubis Therefore, follicles do not mature, ovulation is Most IUD users are over the age of 30. Although
c. In the lower-right maternal abdominal b. Sacral promontory inhibited, and pregnancy is prevented. The there is a slightly higher risk for infertility in
quadrant c. Ischial spines estrogen content of the oral site contraceptive women who have never been pregnant, the IUD
d. Above the maternal umbilicus and to the d. Pubic arch may cause the nausea, regardless of when the is an acceptable option as long as the risk-
left of midline pill is taken. Side effects and drug interactions benefit ratio is discussed. IUDs may be inserted
49. When teaching a group of adolescents about may occur with oral contraceptives regardless of immediately after delivery, but this is not
43. The amniotic fluid of a client has a greenish tint. variations in the length of the menstrual cycle, the time the pill is taken. recommended because of the increased risk and
The nurse interprets this to be the result of the nurse understands that the underlying 2. C. Condoms, when used correctly and rate of expulsion at this time.
which of the following? mechanism is due to variations in which of the consistently, are the most effective 5. C. During the third trimester, the enlarging
a. Lanugo following phases? contraceptive method or barrier against uterus places pressure on the intestines. This
b. Hydramnio a. Menstrual phase bacterial and viral sexually transmitted coupled with the effect of hormones on smooth
c. Meconium b. Proliferative phase infections. Although spermicides kill sperm, they muscle relaxation causes decreased intestinal
d. Vernix c. Secretory phase do not provide reliable protection against the motility (peristalsis). Increasing fiber in the diet
d. Ischemic phase spread of sexually transmitted infections, will help fecal matter pass more quickly through
44. A patient is in labor and has just been told she especially intracellular organisms such as HIV. the intestinal tract, thus decreasing the amount
has a breech presentation. The nurse should be 50. When teaching a group of adolescents about Insertion and removal of the diaphragm along of water that is absorbed. As a result, stool is
particularly alert for which of the following? male hormone production, which of the with the use of the spermicides may cause softer and easier to pass. Enemas could
a. Quickening following would the nurse include as being vaginal irritations, which could place the client at precipitate preterm labor and/or electrolyte loss
b. Ophthalmia neonatorum produced by the Leydig cells? risk for infection transmission. Male sterilization and should be avoided. Laxatives may cause
c. Pica a. Follicle-stimulating hormone eliminates spermatozoa from the ejaculate, but preterm labor by stimulating peristalsis and may
d. Prolapsed umbilical cord b. Testosterone it does not eliminate bacterial and/or viral interfere with the absorption of nutrients. Use
c. Leuteinizing hormone microorganisms that can cause sexually for more than 1 week can also lead to laxative
45. When describing dizygotic twins to a couple, on d. Gonadotropin releasing hormone transmitted infections. dependency. Liquid in the diet helps provide a
which of the following would the nurse base the 3. A. The diaphragm must be fitted individually to semisolid, soft consistency to the stool. Eight to
explanation? ensure effectiveness. Because of the changes to ten glasses of fluid per day are essential to
a. Two ova fertilized by separate sperm the reproductive structures during pregnancy maintain hydration and promote stool
b. Sharing of a common placenta and following delivery, the diaphragm must be evacuation.
c. Each ova with the same genotype refitted, usually at the 6 weeks’ examination 6. D. To ensure adequate fetal growth and
d. Sharing of a common chorion following childbirth or after a weight loss of 15 development during the 40 weeks of a
lbs or more. In addition, for maximum pregnancy, a total weight gain 25 to 30 pounds is
46. Which of the following refers to the single cell effectiveness, spermicidal jelly should be placed recommended: 1.5 pounds in the first 10 weeks;
that reproduces itself after conception? in the dome and around the rim. However, 9 pounds by 30 weeks; and 27.5 pounds by 40
a. Chromosome spermicidal jelly should not be inserted into the weeks. The pregnant woman should gain less
b. Blastocyst vagina until involution is completed at weight in the first and second trimester than in
c. Zygote approximately 6 weeks. Use of a female condom the third. During the first trimester, the client
d. Trophoblast protects the reproductive system from the should only gain 1.5 pounds in the first 10
introduction of semen or spermicides into the weeks, not 1 pound per week. A weight gain of ½
47. In the late 1950s, consumers and health care vagina and may be used after childbirth. Oral pound per week would be 20 pounds for the
professionals began challenging the routine use contraceptives may be started within the first total pregnancy, less than the recommended
of analgesics and anesthetics during childbirth. postpartum week to ensure suppression of amount.
Which of the following was an outgrowth of this ovulation. For the couple who has determined 7. B. To calculate the EDD by Nagele’s rule, add 7
concept? the female’s fertile period, using the rhythm days to the first day of the last menstrual period
a. Labor, delivery, recovery, postpartum method, avoidance of intercourse during this and count back 3 months, changing the year
(LDRP) period, is safe and effective. appropriately. To obtain a date of September 27,
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7 days have been added to the last day of the suspected, which may be caused by fluid ease of correct latching-on for feeding. Narcotics 18. A. The data suggests an infection of the
LMP (rather than the first day of the LMP), plus 4 retention manifested by edema, especially of the administered prior to breast feeding are passed endometrial lining of the uterus. The lochia may
months (instead of 3 months) were counted hands and face. The three classic signs of through the breast milk to the infant, causing be decreased or copious, dark brown in
back. To obtain the date of November 7, 7 days preeclampsia are hypertension, edema, and excessive sleepiness. Nipple soreness is not appearance, and foul smelling, providing further
have been subtracted (instead of added) from proteinuria. Although urine is checked for severe enough to warrant narcotic analgesia. All evidence of a possible infection. All the client’s
the first day of LMP plus November indicates glucose at each clinic visit, this is not the priority. postpartum clients, especially lactating mothers, data indicate a uterine problem, not a breast
counting back 2 months (instead of 3 months) Depression may cause either anorexia or should wear a supportive brassiere with wide problem. Typically, transient fever, usually
from January. To obtain the date of December excessive food intake, leading to excessive cotton straps. This does not, however, prevent 101ºF, may be present with breast
27, 7 days were added to the last day of the LMP weight gain or loss. This is not, however, the or reduce nipple soreness. Soaps are drying to engorgement. Symptoms of mastitis include
(rather than the first day of the LMP) and priority consideration at this time. Weight gain the skin of the nipples and should not be used influenza-like manifestations. Localized infection
December indicates counting back only 1 month thought to be caused by excessive food intake on the breasts of lactating mothers. Dry nipple of an episiotomy or C-section incision rarely
(instead of 3 months) from January. would require a 24-hour diet recall. However, skin predisposes to cracks and fissures, which causes systemic symptoms, and uterine
8. D. The client has been pregnant four times, excessive intake would not be the primary can become sore and painful. involution would not be affected. The client data
including current pregnancy (G). Birth at 38 consideration for this client at this time. 16. D. A weak, thready pulse elevated to 100 BPM do not include dysuria, frequency, or urgency,
weeks’ gestation is considered full term (T), 12. B. Cramping and vaginal bleeding coupled with may indicate impending hemorrhagic shock. An symptoms of urinary tract infections, which
while birth form 20 weeks to 38 weeks is cervical dilation signifies that termination of the increased pulse is a compensatory mechanism of would necessitate assessing the client’s urine.
considered preterm (P). A spontaneous abortion pregnancy is inevitable and cannot be the body in response to decreased fluid volume. 19. C. Because of early postpartum discharge and
occurred at 8 weeks (A). She has two living prevented. Thus, the nurse would document an Thus, the nurse should check the amount of limited time for teaching, the nurse’s priority is
children (L). imminent abortion. In a threatened abortion, lochia present. Temperatures up to 100.48F in to facilitate the safe and effective care of the
9. B. At 12 weeks gestation, the uterus rises out of cramping and vaginal bleeding are present, but the first 24 hours after birth are related to the client and newborn. Although promoting
the pelvis and is palpable above the symphysis there is no cervical dilation. The symptoms may dehydrating effects of labor and are considered comfort and restoration of health, exploring the
pubis. The Doppler intensifies the sound of the subside or progress to abortion. In a complete normal. Although rechecking the blood pressure family’s emotional status, and teaching about
fetal pulse rate so it is audible. The uterus has abortion all the products of conception are may be a correct choice of action, it is not the family planning are important in
merely risen out of the pelvis into the abdominal expelled. A missed abortion is early fetal first action that should be implemented in light postpartum/newborn nursing care, they are not
cavity and is not at the level of the umbilicus. intrauterine death without expulsion of the of the other data. The data indicate a potential the priority focus in the limited time presented
The fetal heart rate at this age is not audible products of conception. impending hemorrhage. Assessing the uterus for by early post-partum discharge.
with a stethoscope. The uterus at 12 weeks is 13. B. For the client with an ectopic pregnancy, firmness and position in relation to the umbilicus 20. C. Heat loss by radiation occurs when the
just above the symphysis pubis in the abdominal lower abdominal pain, usually unilateral, is the and midline is important, but the nurse should infant’s crib is placed too near cold walls or
cavity, not midway between the umbilicus and primary symptom. Thus, pain is the priority. check the extent of vaginal bleeding first. Then it windows. Thus placing the newborn’s crib close
the xiphoid process. At 12 weeks the FHR would Although the potential for infection is always would be appropriate to check the uterus, which to the viewing window would be least effective.
be difficult to auscultate with a fetoscope. present, the risk is low in ectopic pregnancy may be a possible cause of the hemorrhage. Body heat is lost through evaporation during
Although the external electronic fetal monitor because pathogenic microorganisms have not 17. D. Any bright red vaginal discharge would be bathing. Placing the infant under the radiant
would project the FHR, the uterus has not risen been introduced from external sources. The considered abnormal, but especially 5 days after warmer after bathing will assist the infant to be
to the umbilicus at 12 weeks. client may have a limited knowledge of the delivery, when the lochia is typically pink to rewarmed. Covering the scale with a warmed
10. A. Although all of the choices are important in pathology and treatment of the condition and brownish. Lochia rubra, a dark red discharge, is blanket prior to weighing prevents heat loss
the management of diabetes, diet therapy is the will most likely experience grieving, but this is present for 2 to 3 days after delivery. Bright red through conduction. A knit cap prevents heat
mainstay of the treatment plan and should not the priority at this time. vaginal bleeding at this time suggests late loss from the head a large head, a large body
always be the priority. Women diagnosed with 14. D. Before uterine assessment is performed, it is postpartum hemorrhage, which occurs after the surface area of the newborn’s body.
gestational diabetes generally need only diet essential that the woman empty her bladder. A first 24 hours following delivery and is generally 21. B. A fractured clavicle would prevent the normal
therapy without medication to control their full bladder will interfere with the accuracy of caused by retained placental fragments or Moro response of symmetrical sequential
blood sugar levels. Exercise, is important for all the assessment by elevating the uterus and bleeding disorders. Lochia rubra is the normal extension and abduction of the arms followed by
pregnant women and especially for diabetic displacing to the side of the midline. Vital sign dark red discharge occurring in the first 2 to 3 flexion and adduction. In talipes equinovarus
women, because it burns up glucose, thus assessment is not necessary unless an days after delivery, containing epithelial cells, (clubfoot) the foot is turned medially, and in
decreasing blood sugar. However, dietary intake, abnormality in uterine assessment is identified. erythrocyes, leukocytes and decidua. Lochia plantar flexion, with the heel elevated. The feet
not exercise, is the priority. All pregnant women Uterine assessment should not cause acute pain serosa is a pink to brownish serosanguineous are not involved with the Moro reflex.
with diabetes should have periodic monitoring that requires administration of analgesia. discharge occurring from 3 to 10 days after Hypothyroiddism has no effect on the primitive
of serum glucose. However, those with Ambulating the client is an essential component delivery that contains decidua, erythrocytes, reflexes. Absence of the Moror reflex is the most
gestational diabetes generally do not need daily of postpartum care, but is not necessary prior to leukocytes, cervical mucus, and microorganisms. significant single indicator of central nervous
glucose monitoring. The standard of care assessment of the uterus. Lochia alba is an almost colorless to yellowish system status, but it is not a sign of increased
recommends a fasting and 2- hour postprandial 15. A. Feeding more frequently, about every 2 discharge occurring from 10 days to 3 weeks intracranial pressure.
blood sugar level every 2 weeks. hours, will decrease the infant’s frantic, vigorous after delivery and containing leukocytes, 22. B. Hemorrhage is a potential risk following any
11. C. After 20 weeks’ gestation, when there is a sucking from hunger and will decrease breast decidua, epithelial cells, fat, cervical mucus, surgical procedure. Although the infant has been
rapid weight gain, preeclampsia should be engorgement, soften the breast, and promote cholesterol crystals, and bacteria. given vitamin K to facilitate clotting, the
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prophylactic dose is often not sufficient to for gastrointestinal problems. Even though the erectile tissue found in the perineal area above 39. D. The signs indicate placenta previa and vaginal
prevent bleeding. Although infection is a skin is stained with meconium, it is noninfectious the urethra. The parotid glands are open into the exam to determine cervical dilation would not
possibility, signs will not appear within 4 hours (sterile) and nonirritating. The postterm mouth. Skene’s glands open into the posterior be done because it could cause hemorrhage.
after the surgical procedure. The primary meconium- stained infant is not at additional risk wall of the female urinary meatus. Assessing maternal vital signs can help
discomfort of circumcision occurs during the for bowel or urinary problems. 33. D. The fetal gonad must secrete estrogen for the determine maternal physiologic status. Fetal
surgical procedure, not afterward. Although 28. C. The nurse should use a nonelastic, flexible, embryo to differentiate as a female. An increase heart rate is important to assess fetal well-being
feedings are withheld prior to the circumcision, paper measuring tape, placing the zero point on in maternal estrogen secretion does not affect and should be done. Monitoring the contractions
the chances of dehydration are minimal. the superior border of the symphysis pubis and differentiation of the embryo, and maternal will help evaluate the progress of labor.
23. B. The presence of excessive estrogen and stretching the tape across the abdomen at the estrogen secretion occurs in every pregnancy. 40. D. A complete placenta previa occurs when the
progesterone in the maternal- fetal blood midline to the top of the fundus. The xiphoid and Maternal androgen secretion remains the same placenta covers the opening of the uterus, thus
followed by prompt withdrawal at birth umbilicus are not appropriate landmarks to use as before pregnancy and does not affect blocking the passageway for the baby. This
precipitates breast engorgement, which will when measuring the height of the fundus differentiation. Secretion of androgen by the response explains what a complete previa is and
spontaneously resolve in 4 to 5 days after birth. (McDonald’s measurement). fetal gonad would produce a male fetus. the reason the baby cannot come out except by
The trauma of the birth process does not cause 29. B. Women hospitalized with severe 34. A. Using bicarbonate would increase the amount cesarean delivery. Telling the client to ask the
inflammation of the newborn’s breast tissue. preeclampsia need decreased CNS stimulation to of sodium ingested, which can cause physician is a poor response and would increase
Newborns do not have breast malignancy. This prevent a seizure. Seizure precautions provide complications. Eating low-sodium crackers the patient’s anxiety. Although a cesarean would
reply by the nurse would cause the mother to environmental safety should a seizure occur. would be appropriate. Since liquids can increase help to prevent hemorrhage, the statement does
have undue anxiety. Breast tissue does not Because of edema, daily weight is important but nausea avoiding them in the morning hours not explain why the hemorrhage could occur.
hypertrophy in the fetus or newborns. not the priority. Preclampsia causes vasospasm when nausea is usually the strongest is With a complete previa, the placenta is covering
24. D. The first 15 minutes to 1 hour after birth is and therefore can reduce utero-placental appropriate. Eating six small meals a day would the entire cervix, not just most of it.
the first period of reactivity involving respiratory perfusion. The client should be placed on her left keep the stomach full, which often decrease 41. B. With a face presentation, the head is
and circulatory adaptation to extrauterine life. side to maximize blood flow, reduce blood nausea. completely extended. With a vertex
The data given reflect the normal changes during pressure, and promote diuresis. Interventions to 35. B. Ballottement indicates passive movement of presentation, the head is completely or partially
this time period. The infant’s assessment data reduce stress and anxiety are very important to the unengaged fetus. Ballottement is not a flexed. With a brow (forehead) presentation, the
reflect normal adaptation. Thus, the physician facilitate coping and a sense of control, but contraction. Fetal kicking felt by the client head would be partially extended.
does not need to be notified and oxygen is not seizure precautions are the priority. represents quickening. Enlargement and 42. D. With this presentation, the fetal upper torso
needed. The data do not indicate the presence 30. C. Cessation of the lochial discharge signifies softening of the uterus is known as Piskacek’s and back face the left upper maternal abdominal
of choking, gagging or coughing, which are signs healing of the endometrium. Risk of hemorrhage sign. wall. The fetal heart rate would be most audible
of excessive secretions. Suctioning is not and infection are minimal 3 weeks after a 36. B. Chadwick’s sign refers to the purple-blue tinge above the maternal umbilicus and to the left of
necessary. normal vaginal delivery. Telling the client of the cervix. Braxton Hicks contractions are the middle. The other positions would be
25. B. Application of 70% isopropyl alcohol to the anytime is inappropriate because this response painless contractions beginning around the 4th incorrect.
cord minimizes microorganisms (germicidal) and does not provide the client with the specific month. Goodell’s sign indicates softening of the 43. C. The greenish tint is due to the presence of
promotes drying. The cord should be kept dry information she is requesting. Choice of a cervix. Flexibility of the uterus against the cervix meconium. Lanugo is the soft, downy hair on the
until it falls off and the stump has healed. contraceptive method is important, but not the is known as McDonald’s sign. shoulders and back of the fetus. Hydramnios
Antibiotic ointment should only be used to treat specific criteria for safe resumption of sexual 37. C. Breathing techniques can raise the pain represents excessive amniotic fluid. Vernix is the
an infection, not as a prophylaxis. Infants should activity. Culturally, the 6- weeks’ examination threshold and reduce the perception of pain. white, cheesy substance covering the fetus.
not be submerged in a tub of water until the has been used as the time frame for resuming They also promote relaxation. Breathing 44. D. In a breech position, because of the space
cord falls off and the stump has completely sexual activity, but it may be resumed earlier. techniques do not eliminate pain, but they can between the presenting part and the cervix,
healed. 31. C. The middle third of the vastus lateralis is the reduce it. Positioning, not breathing, increases prolapse of the umbilical cord is common.
26. B. To determine the amount of formula needed, preferred injection site for vitamin K uteroplacental perfusion. Quickening is the woman’s first perception of
do the following mathematical calculation. 3 kg x administration because it is free of blood vessels 38. A. The client’s labor is hypotonic. The nurse fetal movement. Ophthalmia neonatorum
120 cal/kg per day = 360 calories/day feeding q 4 and nerves and is large enough to absorb the should call the physical and obtain an order for usually results from maternal gonorrhea and is
hours = 6 feedings per day = 60 calories per medication. The deltoid muscle of a newborn is an infusion of oxytocin, which will assist the conjunctivitis. Pica refers to the oral intake of
feeding: 60 calories per feeding; 60 calories per not large enough for a newborn IM injection. uterus to contact more forcefully in an attempt nonfood substances.
feeding with formula 20 cal/oz = 3 ounces per Injections into this muscle in a small child might to dilate the cervix. Administering light sedative 45. A. Dizygotic (fraternal) twins involve two ova
feeding. Based on the calculation. 2, 4 or 6 cause damage to the radial nerve. The anterior would be done for hypertonic uterine fertilized by separate sperm. Monozygotic
ounces are incorrect. femoris muscle is the next safest muscle to use contractions. Preparing for cesarean section is (identical) twins involve a common placenta,
27. A. Intrauterine anoxia may cause relaxation of in a newborn but is not the safest. Because of unnecessary at this time. Oxytocin would same genotype, and common chorion.
the anal sphincter and emptying of meconium the proximity of the sciatic nerve, the gluteus increase the uterine contractions and hopefully 46. C. The zygote is the single cell that reproduces
into the amniotic fluid. At birth some of the maximus muscle should not be until the child progress labor before a cesarean would be itself after conception. The chromosome is the
meconium fluid may be aspirated, causing has been walking 2 years. necessary. It is too early to anticipate client material that makes up the cell and is gained
mechanical obstruction or chemical 32. D. Bartholin’s glands are the glands on either pushing with contractions. from each parent. Blastocyst and trophoblast are
pneumonitis. The infant is not at increased risk side of the vaginal orifice. The clitoris is female later terms for the embryo after zygote.
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47. D. Prepared childbirth was the direct result of MEDICAL SURGICAL NURSING c. Perineal edema
the 1950’s challenging of the routine use of d. Urethral discharge
analgesic and anesthetics during childbirth. The 1. Marco who was diagnosed with brain tumor was
LDRP was a much later concept and was not a scheduled for craniotomy. In preventing the 7. A client has undergone with penile implant.
direct result of the challenging of routine use of development of cerebral edema after surgery, After 24 hrs of surgery, the client’s scrotum was
analgesics and anesthetics during childbirth. the nurse should expect the use of: edematous and painful. The nurse should:
Roles for nurse midwives and clinical nurse a. Diuretics a. Assist the client with sitz bath
specialists did not develop from this challenge. b. Antihypertensive b. Apply war soaks in the scrotum
48. C. The ischial spines are located in the mid-pelvic c. Steroids c. Elevate the scrotum using a soft support
region and could be narrowed due to the d. Anticonvulsants d. Prepare for a possible incision and
previous pelvic injury. The symphysis pubis, drainage.
sacral promontory, and pubic arch are not part 2. Halfway through the administration of blood,
of the mid-pelvis. the female client complains of lumbar pain. After 8. Nurse hazel receives emergency laboratory
49. B. Variations in the length of the menstrual cycle stopping the infusion Nurse Hazel should: results for a client with chest pain and
are due to variations in the proliferative phase. a. Increase the flow of normal saline immediately informs the physician. An increased
The menstrual, secretory and ischemic phases b. Assess the pain further myoglobin level suggests which of the following?
do not contribute to this variation. c. Notify the blood bank a. Liver disease
50. B. Testosterone is produced by the Leyding cells d. Obtain vital signs. b. Myocardial damage
in the seminiferous tubules. Follicle-stimulating c. Hypertension
hormone and leuteinzing hormone are released 3. Nurse Maureen knows that the positive d. Cancer
by the anterior pituitary gland. The diagnosis for HIV infection is made based on
hypothalamus is responsible for releasing which of the following: 9. Nurse Maureen would expect the client with
gonadotropin-releasing hormone. a. A history of high risk sexual behaviors. mitral stenosis would demonstrate symptoms
b. Positive ELISA and western blot tests associated with congestion in the:
c. Identification of an associated a. Right atrium
opportunistic infection b. Superior vena cava
d. Evidence of extreme weight loss and c. Aorta
high fever d. Pulmonary
4. Nurse Maureen is aware that a client who has 10. A client has been diagnosed with hypertension.
been diagnosed with chronic renal failure The nurse priority nursing diagnosis would be:
recognizes an adequate amount of high-biologic- a. Ineffective health maintenance
value protein when the food the client selected b. Impaired skin integrity
from the menu was: c. Deficient fluid volume
a. Raw carrots d. Pain
b. Apple juice
c. Whole wheat bread 11. Nurse Hazel teaches the client with angina about
d. Cottage cheese common expected side effects of nitroglycerin
including:
5. Kenneth who has diagnosed with uremic a. high blood pressure
syndrome has the potential to develop b. stomach cramps
complications. Which among the following c. headache
complications should the nurse anticipates: d. shortness of breath
a. Flapping hand tremors
b. An elevated hematocrit level 12. The following are lipid abnormalities. Which of
c. Hypotension the following is a risk factor for the development
d. Hypokalemia of atherosclerosis and PVD?
a. High levels of low density lipid (LDL)
6. A client is admitted to the hospital with benign cholesterol
prostatic hyperplasia, the nurse most relevant b. High levels of high density lipid (HDL)
assessment would be: cholesterol
a. Flank pain radiating in the groin c. Low concentration triglycerides
b. Distention of the lower abdomen d. Low levels of LDL cholesterol.
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b. Administering Coumadin c. Lower cost with reusable insulin

13. Which of the following represents a significant c. Treating the underlying cause cartridges 30. A male client has undergone spinal surgery, the
risk immediately after surgery for repair of aortic d. Replacing depleted blood products d. Use of smaller gauge needle. nurse should:
aneurysm? a. Observe the client’s bowel movement
a. Potential wound infection 20. Which of the following findings is the best 25. A male client’s left tibia is fractures in an and voiding patterns
b. Potential ineffective coping indication that fluid replacement for the client automobile accident, and a cast is applied. To b. Log-roll the client to prone position
c. Potential electrolyte balance with hypovolemic shock is adequate? assess for damage to major blood vessels from c. Assess the client’s feet for sensation and
d. Potential alteration in renal perfusion a. Urine output greater than 30ml/hr the fracture tibia, the nurse in charge should circulation
b. Respiratory rate of 21 breaths/minute monitor the client for: d. Encourage client to drink plenty of fluids
14. Nurse Josie should instruct the client to eat c. Diastolic blood pressure greater than 90 a. Swelling of the left thigh
which of the following foods to obtain the best mmhg b. Increased skin temperature of the foot 31. Marina with acute renal failure moves into the
supply of Vitamin B12? d. Systolic blood pressure greater than 110 c. Prolonged reperfusion of the toes after diuretic phase after one week of therapy. During
a. dairy products mmhg blanching this phase the client must be assessed for signs
b. vegetables d. Increased blood pressure of developing:
c. Grains 21. Which of the following signs and symptoms a. Hypovolemia
d. Broccoli would Nurse Maureen include in teaching plan 26. After a long leg cast is removed, the male client b. renal failure
as an early manifestation of laryngeal cancer? should: c. metabolic acidosis
15. Karen has been diagnosed with aplastic anemia. a. Stomatitis a. Cleanse the leg by scrubbing with a brisk d. hyperkalemia
The nurse monitors for changes in which of the b. Airway obstruction motion
following physiologic functions? c. Hoarseness b. Put leg through full range of motion 32. Nurse Judith obtains a specimen of clear nasal
a. Bowel function d. Dysphagia twice daily drainage from a client with a head injury. Which
b. Peripheral sensation c. Report any discomfort or stiffness to the of the following tests differentiates mucus from
c. Bleeding tendencies 22. Karina a client with myasthenia gravis is to physician cerebrospinal fluid (CSF)?
d. Intake and out put receive immunosuppressive therapy. The nurse d. Elevate the leg when sitting for long a. Protein
understands that this therapy is effective periods of time. b. Specific gravity
16. Lydia is scheduled for elective splenectomy. because it: c. Glucose
Before the clients goes to surgery, the nurse in a. Promotes the removal of antibodies that 27. While performing a physical assessment of a d. Microorganism
charge final assessment would be: impair the transmission of impulses male client with gout of the great toe,
a. signed consent b. Stimulates the production of NurseVivian should assess for additional tophi 33. A 22 year old client suffered from his first tonic-
b. vital signs acetylcholine at the neuromuscular (urate deposits) on the: clonic seizure. Upon awakening the client asks
c. name band junction. a. Buttocks the nurse, “What caused me to have a seizure?
d. empty bladder c. Decreases the production of b. Ears Which of the following would the nurse include
autoantibodies that attack the c. Face in the primary cause of tonic-clonic seizures in
17. What is the peak age range in acquiring acute acetylcholine receptors. d. Abdomen adults more the 20 years?
lymphocytic leukemia (ALL)? d. Inhibits the breakdown of acetylcholine a. Electrolyte imbalance
a. 4 to 12 years. at the neuromuscular junction. 28. Nurse Katrina would recognize that the b. Head trauma
b. 20 to 30 years demonstration of crutch walking with tripod gait c. Epilepsy
c. 40 to 50 years 23. A female client is receiving IV Mannitol. An was understood when the client places weight d. Congenital defect
d. 60 60 70 years assessment specific to safe administration of the on the:
said drug is: a. Palms of the hands and axillary regions 34. What is the priority nursing assessment in the
18. Marie with acute lymphocytic leukemia suffers a. Vital signs q4h b. Palms of the hand first 24 hours after admission of the client with
from nausea and headache. These clinical b. Weighing daily c. Axillary regions thrombotic CVA?
manifestations may indicate all of the following c. Urine output hourly d. Feet, which are set apart a. Pupil size and papillary response
except d. Level of consciousness q4h b. cholesterol level
a. effects of radiation 29. Mang Jose with rheumatoid arthritis states, “the c. Echocardiogram
b. chemotherapy side effects 24. Patricia a 20 year old college student with only time I am without pain is when I lie in bed d. Bowel sounds
c. meningeal irritation diabetes mellitus requests additional perfectly still”. During the convalescent stage,
d. gastric distension information about the advantages of using a pen the nurse in charge with Mang Jose should 35. Nurse Linda is preparing a client with multiple
like insulin delivery devices. The nurse explains encourage: sclerosis for discharge from the hospital to
19. A client has been diagnosed with Disseminated that the advantages of these devices over a. Active joint flexion and extension home. Which of the following instruction is most
Intravascular Coagulation (DIC). Which of the syringes include: b. Continued immobility until pain subsides appropriate?
following is contraindicated with the client? a. Accurate dose delivery c. Range of motion exercises twice daily
a. Administering Heparin b. Shorter injection time d. Flexion exercises three times daily
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a. “Practice using the mechanical aids that d. A client with U.T.I 49. Nurse Anna is aware that early adaptation of
you will need when future disabilities client with renal carcinoma is:
arise”. 42. Among the following clients, which among them a. Nausea and vomiting
b. “Follow good health habits to change is high risk for potential hazards from the b. flank pain
the course of the disease”. surgical experience? c. weight gain
c. “Keep active, use stress reduction a. 67-year-old client d. intermittent hematuria
strategies, and avoid fatigue. b. 49-year-old client
d. “You will need to accept the necessity c. 33-year-old client 50. A male client with tuberculosis asks Nurse Brian
for a quiet and inactive lifestyle”. d. 15-year-old client how long the chemotherapy must be continued.
Nurse Brian’s accurate reply would be:
36. The nurse is aware the early indicator of hypoxia 43. Nurse Jon assesses vital signs on a client a. 1 to 3 weeks
in the unconscious client is: undergone epidural anesthesia. b. 6 to 12 months
a. Cyanosis 44. Which of the following would the nurse assess c. 3 to 5 months
b. Increased respirations next? d. 3 years and more
c. Hypertension a. Headache
d. Restlessness b. Bladder distension 51. A client has undergone laryngectomy. The
c. Dizziness immediate nursing priority would be:
37. A client is experiencing spinal shock. Nurse d. Ability to move legs a. Keep trachea free of secretions
Myrna should expect the function of the bladder b. Monitor for signs of infection
to be which of the following? 45. Nurse Katrina should anticipate that all of the c. Provide emotional support
a. Normal following drugs may be used in the attempt to d. Promote means of communication
b. Atonic control the symptoms of Meniere's disease
c. Spastic except:
d. Uncontrolled a. Antiemetics
b. Diuretics
38. Which of the following stage the carcinogen is c. Antihistamines
irreversible? d. Glucocorticoids
a. Progression stage
b. Initiation stage 46. Which of the following complications associated
c. Regression stage with tracheostomy tube?
d. Promotion stage a. Increased cardiac output
b. Acute respiratory distress syndrome
39. Among the following components thorough pain (ARDS)
assessment, which is the most significant? c. Increased blood pressure
a. Effect d. Damage to laryngeal nerves
b. Cause
c. Causing factors 47. Nurse Faith should recognize that fluid shift in a
d. Intensity client with burn injury results from increase in
the:
40. A 65 year old female is experiencing flare up of a. Total volume of circulating whole blood
pruritus. Which of the client’s action could b. Total volume of intravascular plasma
aggravate the cause of flare ups? c. Permeability of capillary walls
a. Sleeping in cool and humidified d. Permeability of kidney tubules
environment
b. Daily baths with fragrant soap 48. An 83-year-old woman has several ecchymotic
c. Using clothes made from 100% cotton areas on her right arm. The bruises are probably
d. Increasing fluid intake caused by:
a. increased capillary fragility and
41. Atropine sulfate (Atropine) is contraindicated in permeability
all but one of the following client? b. increased blood supply to the skin
a. A client with high blood c. self-inflicted injury
b. A client with bowel obstruction d. elder abuse
c. A client with glaucoma
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ANSWERS AND RATIONALE – MEDICAL SURGICAL 14. A. Good source of vitamin B12 are dairy where blood flow is least active, including 43. B. The last area to return sensation is in the
NURSING products and meats. cartilaginous tissue such as the ears. perineal area, and the nurse in charge should
15. C. Aplastic anemia decreases the bone marrow 28. B. The palms should bear the client’s weight to monitor the client for distended bladder.
1. C. Glucocorticoids (steroids) are used for their production of RBC’s, white blood cells, and avoid damage to the nerves in the axilla. 44. D. Glucocorticoids play no significant role in
anti-inflammatory action, which decreases the platelets. The client is at risk for bruising and 29. A. Active exercises, alternating extension, disease treatment.
development of edema. bleeding tendencies. flexion, abduction, and adduction, mobilize 45. D. Tracheostomy tube has several potential
2. A. The blood must be stopped at once, and then 16. B. An elective procedure is scheduled in advance exudates in the joints relieves stiffness and pain. complications including bleeding, infection and
normal saline should be infused to keep the line so that all preparations can be completed ahead 30. C. Alteration in sensation and circulation laryngeal nerve damage.
patent and maintain blood volume. of time. The vital signs are the final check that indicates damage to the spinal cord, if these 46. C. In burn, the capillaries and small vessels
3. B. These tests confirm the presence of HIV must be completed before the client leaves the occurs notify physician immediately. dilate, and cell damage cause the release of a
antibodies that occur in response to the room so that continuity of care and assessment 31. A. In the diuretic phase fluid retained during the histamine-like substance. The substance causes
presence of the human immunodeficiency virus is provided for. oliguric phase is excreted and may reach 3 to 5 the capillary walls to become more permeable
(HIV). 17. A. The peak incidence of Acute Lymphocytic liters daily, hypovolemia may occur and fluids and significant quantities of fluid are lost.
4. D. One cup of cottage cheese contains Leukemia (ALL) is 4 years of age. It is uncommon should be replaced. 47. A. Aging process involves increased capillary
approximately 225 calories, 27g of protein, 9g of after 15 years of age. 32. C. The constituents of CSF are similar to those of fragility and permeability. Older adults have a
fat, 30mg cholesterol, and 6g of carbohydrate. 18. D. Acute Lymphocytic Leukemia (ALL) does not blood plasma. An examination for glucose decreased amount of subcutaneous fat and
Proteins of high biologic value (HBV) contain cause gastric distention. It does invade the content is done to determine whether a body cause an increased incidence of bruise like
optimal levels of amino acids essential for life. central nervous system, and clients experience fluid is a mucus or a CSF. A CSF normally contains lesions caused by collection of extravascular
5. A. Elevation of uremic waste products causes headaches and vomiting from meningeal glucose. blood in loosely structured dermis.
irritation of the nerves, resulting in flapping irritation. 33. B. Trauma is one of the primary causes of brain 48. D. Intermittent pain is the classic sign of renal
hand tremors. 19. B. Disseminated Intravascular Coagulation (DIC) damage and seizure activity in adults. Other carcinoma. It is primarily due to capillary erosion
6. B. This indicates that the bladder is distended has not been found to respond to oral common causes of seizure activity in adults by the cancerous growth.
with urine, therefore palpable. anticoagulants such as Coumadin. include neoplasms, withdrawal from drugs and 49. B. Tubercle bacillus is a drug resistant organism
7. C. Elevation increases lymphatic drainage, 20. A. Urine output provides the most sensitive alcohol, and vascular disease. and takes a long time to be eradicated. Usually a
reducing edema and pain. indication of the client’s response to therapy for 34. A. It is crucial to monitor the pupil size and combination of three drugs is used for minimum
8. B. Detection of myoglobin is a diagnostic tool to hypovolemic shock. Urine output should be papillary response to indicate changes around of 6 months and at least six months beyond
determine whether myocardial damage has consistently greater than 30 to 35 mL/hr. the cranial nerves. culture conversion.
occurred. 21. C. Early warning signs of laryngeal cancer can 35. C. The nurse most positive approach is to 50. A. Patent airway is the most priority; therefore
9. D. When mitral stenosis is present, the left vary depending on tumor location. Hoarseness encourage the client with multiple sclerosis to removal of secretions is necessary
atrium has difficulty emptying its contents into lasting 2 weeks should be evaluated because it is stay active, use stress reduction techniques and
the left ventricle because there is no valve to one of the most common warning signs. avoid fatigue because it is important to support
prevent back ward flow into the pulmonary vein, 22. C. Steroids decrease the body’s immune the immune system while remaining active.
the pulmonary circulation is under pressure. response thus decreasing the production of 36. D. Restlessness is an early indicator of hypoxia.
10. A. Managing hypertension is the priority for the antibodies that attack the acetylcholine The nurse should suspect hypoxia in unconscious
client with hypertension. Clients with receptors at the neuromuscular junction client who suddenly becomes restless.
hypertension frequently do not experience pain, 23. C. The osmotic diuretic mannitol is 37. B. In spinal shock, the bladder becomes
deficient volume, or impaired skin integrity. It is contraindicated in the presence of inadequate completely atonic and will continue to fill unless
the asymptomatic nature of hypertension that renal function or heart failure because it the client is catheterized.
makes it so difficult to treat. increases the intravascular volume that must be 38. A. Progression stage is the change of tumor from
11. C. Because of its widespread vasodilating effects, filtered and excreted by the kidney. the preneoplastic state or low degree of
nitroglycerin often produces side effects such as 24. A. These devices are more accurate because malignancy to a fast growing tumor that cannot
headache, hypotension and dizziness. they are easily to used and have improved be reversed.
12. A. An increased in LDL cholesterol concentration adherence in insulin regimens by young people 39. D. Intensity is the major indicative of severity of
has been documented at risk factor for the because the medication can be administered pain and it is important for the evaluation of the
development of atherosclerosis. LDL cholesterol discreetly. treatment.
is not broken down into the liver but is 25. C. Damage to blood vessels may decrease the 40. B. The use of fragrant soap is very drying to skin
deposited into the wall of the blood vessels. circulatory perfusion of the toes, this would hence causing the pruritus.
13. D. There is a potential alteration in renal indicate the lack of blood supply to the 41. C. Atropine sulfate is contraindicated with
perfusion manifested by decreased urine output. extremity. glaucoma patients because it increases
The altered renal perfusion may be related to 26. D. Elevation will help control the edema that intraocular pressure.
renal artery embolism, prolonged hypotension, usually occurs. 42. A. A 67 year old client is greater risk because the
or prolonged aortic cross-clamping during the 27. B. Uric acid has a low solubility, it tends to older adult client is more likely to have a less-
surgery. precipitate and form deposits at various sites effective immune system.
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PSYCHIATRIC NURSING 7. A 20 year old client was diagnosed with 13. Nurse Trish is working in a mental health facility; following actions by the nurse would be most
dependent personality disorder. Which behavior the nurse priority nursing intervention for a important?
1. Marco approached Nurse Trish asking for advice is not likely to be evidence of ineffective newly admitted client with bulimia nervosa a. Ask a family member to stay with the
on how to deal with his alcohol addiction. Nurse individual coping? would be to? client at home temporarily
Trish should tell the client that the only effective a. Recurrent self-destructive behavior a. Teach client to measure I & O b. Discuss the meaning of the client’s
treatment for alcoholism is: b. Avoiding relationship b. Involve client in planning daily meal statement with her
a. Psychotherapy c. Showing interest in solitary activities c. Observe client during meals c. Request an immediate extension for the
b. Alcoholics anonymous (A.A.) d. Inability to make choices and decision d. Monitor client continuously client
c. Total abstinence without advise d. Ignore the clients statement because it’s
d. Aversion Therapy 14. Nurse Patricia is aware that the major health a sign of manipulation
8. A male client is diagnosed with schizotypal complication associated with intractable
2. Nurse Hazel is caring for a male client who personality disorder. Which signs would this anorexia nervosa would be? 19. Joey a client with antisocial personality disorder
experience false sensory perceptions with no client exhibit during social situation? a. Cardiac dysrhythmias resulting to belches loudly. A staff member asks Joey, “Do
basis in reality. This perception is known as: a. Paranoid thoughts cardiac arrest you know why people find you repulsive?” this
a. Hallucinations b. Emotional affect b. Glucose intolerance resulting in statement most likely would elicit which of the
b. Delusions c. Independence need protracted hypoglycemia following client reaction?
c. Loose associations d. Aggressive behavior c. Endocrine imbalance causing cold a. Depensiveness
d. Neologisms amenorrhea b. Embarrassment
9. Nurse Claire is caring for a client diagnosed with d. Decreased metabolism causing cold c. Shame
3. Nurse Monet is caring for a female client who bulimia. The most appropriate initial goal for a intolerance d. Remorsefulness
has suicidal tendency. When accompanying the client diagnosed with bulimia is?
client to the restroom, Nurse Monet should… a. Encourage to avoid foods 15. Nurse Anna can minimize agitation in a 20. Which of the following approaches would be
a. Give her privacy b. Identify anxiety causing situations disturbed client by? most appropriate to use with a client suffering
b. Allow her to urinate c. Eat only three meals a day a. Increasing stimulation from narcissistic personality disorder when
c. Open the window and allow her to get d. Avoid shopping plenty of groceries b. limiting unnecessary interaction discrepancies exist between what the client
some fresh air c. increasing appropriate sensory states and what actually exist?
d. Observe her 10. Nurse Tony was caring for a 41 year old female perception a. Rationalization
client. Which behavior by the client indicates d. ensuring constant client and staff b. Supportive confrontation
4. Nurse Maureen is developing a plan of care for a adult cognitive development? contact c. Limit setting
female client with anorexia nervosa. Which a. Generates new levels of awareness d. Consistency
action should the nurse include in the plan? b. Assumes responsibility for her actions 16. A 39 year old mother with obsessive-compulsive
a. Provide privacy during meals c. Has maximum ability to solve problems disorder has become immobilized by her 21. Cely is experiencing alcohol withdrawal exhibits
b. Set-up a strict eating plan for the client and learn new skills elaborate hand washing and walking rituals. tremors, diaphoresis and hyperactivity. Blood
c. Encourage client to exercise to reduce d. Her perception are based on reality Nurse Trish recognizes that the basis of O.C. pressure is 190/87 mmhg and pulse is 92 bpm.
anxiety disorder is often: Which of the medications would the nurse
d. Restrict visits with the family 11. A neuromuscular blocking agent is administered a. Problems with being too conscientious expect to administer?
to a client before ECT therapy. The Nurse should b. Problems with anger and remorse a. Naloxone (Narcan)
5. A client is experiencing anxiety attack. The most carefully observe the client for? c. Feelings of guilt and inadequacy b. Benzlropine (Cogentin)
appropriate nursing intervention should include? a. Respiratory difficulties d. Feeling of unworthiness and c. Lorazepam (Ativan)
a. Turning on the television b. Nausea and vomiting hopelessness d. Haloperidol (Haldol)
b. Leaving the client alone c. Dizziness
c. Staying with the client and speaking in d. Seizures 17. Mario is complaining to other clients about not 22. Which of the following foods would the nurse
short sentences being allowed by staff to keep food in his room. Trish eliminate from the diet of a client in
d. Ask the client to play with other clients 12. A 75 year old client is admitted to the hospital Which of the following interventions would be alcohol withdrawal?
with the diagnosis of dementia of the most appropriate? a. Milk
6. A female client is admitted with a diagnosis of Alzheimer’s type and depression. The symptom a. Allowing a snack to be kept in his room b. Orange Juice
delusions of GRANDEUR. This diagnosis reflects a that is unrelated to depression would be? b. Reprimanding the client c. Soda
belief that one is: a. Apathetic response to the environment c. Ignoring the clients behavior d. Regular Coffee
a. Being Killed b. “I don’t know” answer to questions d. Setting limits on the behavior
b. Highly famous and important c. Shallow of labile effect 23. Which of the following would Nurse Hazel
c. Responsible for evil world d. Neglect of personal hygiene 18. Conney with borderline personality disorder who expect to assess for a client who is exhibiting
d. Connected to client unrelated to oneself is to be discharge soon threatens to “do late signs of heroin withdrawal?
something” to herself if discharged. Which of the a. Yawning & diaphoresis
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b. Restlessness & Irritability my best friend. The nurse recognizes that the c. Compulsive behavior, excessive fears & detailed assessment, a diagnosis of
c. Constipation & steatorrhea client is using the defense mechanism known as? nausea schizophrenia is made. It is unlikely that the
d. Vomiting and Diarrhea a. Displacement d. Excessive activity, memory lapses & an client will demonstrate:
b. Projection increased pulse a. Low self esteem
24. To establish open and trusting relationship with c. Sublimation b. Concrete thinking
a female client who has been hospitalized with d. Denial 35. A characteristic that would suggest to Nurse c. Effective self-boundaries
severe anxiety, the nurse in charge should? Anne that an adolescent may have bulimia d. Weak ego
a. Encourage the staff to have frequent 30. When working with a male client suffering would be:
interaction with the client phobia about black cats, Nurse Trish should a. Frequent regurgitation & re-swallowing 41. A 23 year old client has been admitted with a
b. Share an activity with the client anticipate that a problem for this client would of food diagnosis of schizophrenia says to the nurse
c. Give client feedback about behavior be? b. Previous history of gastritis “Yes, its march, March is little woman”. That’s
d. Respect client’s need for personal space a. Anxiety when discussing phobia c. Badly stained teeth literal you know”. These statement illustrate:
b. Anger toward the feared object d. Positive body image a. Neologisms
25. Nurse Monette recognizes that the focus of c. Denying that the phobia exist b. Echolalia
environmental (MILIEU) therapy is to: d. Distortion of reality when completing 36. Nurse Monette is aware that extremely c. Flight of ideas
a. Manipulate the environment to bring daily routines depressed clients seem to do best in settings d. Loosening of association
about positive changes in behavior where they have:
b. Allow the client’s freedom to determine 31. Linda is pacing the floor and appears extremely a. Multiple stimuli 42. A long term goal for a paranoid male client who
whether or not they will be involved in anxious. The duty nurse approaches in an b. Routine Activities has unjustifiably accused his wife of having many
activities attempt to alleviate Linda’s anxiety. The most c. Minimal decision making extramarital affairs would be to help the client
c. Role play life events to meet individual therapeutic question by the nurse would be? d. Varied Activities develop:
needs a. Would you like to watch TV? a. Insight into his behavior
d. Use natural remedies rather than drugs b. Would you like me to talk with you? 37. To further assess a client’s suicidal potential. b. Better self-control
to control behavior c. Are you feeling upset now? Nurse Katrina should be especially alert to the c. Feeling of self-worth
d. Ignore the client client expression of: d. Faith in his wife
26. Nurse Trish would expect a child with a diagnosis a. Frustration & fear of death
of reactive attachment disorder to: 32. Nurse Penny is aware that the symptoms that b. Anger & resentment 43. A male client who is experiencing disordered
a. Have more positive relation with the distinguish post-traumatic stress disorder from c. Anxiety & loneliness thinking about food being poisoned is admitted
father than the mother other anxiety disorder would be: d. Helplessness & hopelessness to the mental health unit. The nurse uses which
b. Cling to mother & cry on separation a. Avoidance of situation & certain communication technique to encourage the
c. Be able to develop only superficial activities that resemble the stress 38. A nursing care plan for a male client with bipolar client to eat dinner?
relation with the others b. Depression and a blunted affect when I disorder should include: a. Focusing on self-disclosure of own food
d. Have been physically abuse discussing the traumatic situation a. Providing a structured environment preference
c. Lack of interest in family & others b. Designing activities that will require the b. Using open ended question and silence
27. When teaching parents about childhood d. Re-experiencing the trauma in dreams or client to maintain contact with reality c. Offering opinion about the need to eat
depression Nurse Trina should say? flashback c. Engaging the client in conversing about d. Verbalizing reasons that the client may
a. It may appear acting out behavior current affairs not choose to eat
b. Does not respond to conventional 33. Nurse Benjie is communicating with a male client d. Touching the client provide assurance
treatment with substance-induced persisting dementia; the 44. Nurse Nina is assigned to care for a client
c. Is short in duration & resolves easily client cannot remember facts and fills in the 39. When planning care for a female client using diagnosed with Catatonic Stupor. When Nurse
d. Looks almost identical to adult gaps with imaginary information. Nurse Benjie is ritualistic behavior, Nurse Gina must recognize Nina enters the client’s room, the client is found
depression aware that this is typical of? that the ritual: lying on the bed with a body pulled into a fetal
a. Flight of ideas a. Helps the client focus on the inability to position. Nurse Nina should?
28. Nurse Perry is aware that language development b. Associative looseness deal with reality a. Ask the client direct questions to
in autistic child resembles: c. Confabulation b. Helps the client control the anxiety encourage talking
a. Scanning speech d. Concretism c. Is under the client’s conscious control b. Rake the client into the dayroom to be
b. Speech lag d. Is used by the client primarily for with other clients
c. Shuttering 34. Nurse Joey is aware that the signs & symptoms secondary gains c. Sit beside the client in silence and
d. Echolalia that would be most specific for diagnosis occasionally ask open-ended question
anorexia are? 40. A 32 year old male graduate student, who has d. Leave the client alone and continue with
29. A 60 year old female client who lives alone tells a. Excessive weight loss, amenorrhea & become increasingly withdrawn and neglectful providing care to the other clients
the nurse at the community health center “I abdominal distension of his work and personal hygiene, is brought to
really don’t need anyone to talk to”. The TV is b. Slow pulse, 10% weight loss & alopecia the psychiatric hospital by his parents. After
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45. Nurse Tina is caring for a client with delirium and 49. Nurse Tina is caring for a client with depression ANSWERS AND RATIONALE – PSYCHIATRIC Rationale: With depression, there is little or no
states that “look at the spiders on the wall”. who has not responded to antidepressant NURSING emotional involvement therefore little alteration
What should the nurse respond to the client? medication. The nurse anticipates that what in affect.
a. “You’re having hallucination, there are treatment procedure may be prescribed. 1. Answer: C 13. Answer: D
no spiders in this room at all” a. Neuroleptic medication Rationale: Total abstinence is the only effective Rationale: These clients often hide food or force
b. “I can see the spiders on the wall, but b. Short term seclusion treatment for alcoholism vomiting; therefore they must be carefully
they are not going to hurt you” c. Psychosurgery 2. Answer: A monitored.
c. “Would you like me to kill the spiders” d. Electroconvulsive therapy Rationale: Hallucinations are visual, auditory, 14. Answer: A
d. “I know you are frightened, but I do not gustatory, tactile or olfactory perceptions that Rationale: These clients have severely depleted
see spiders on the wall” 50. Mario is admitted to the emergency room with have no basis in reality. levels of sodium and potassium because of their
drug-included anxiety related to over ingestion 3. Answer: D starvation diet and energy expenditure, these
46. Nurse Jonel is providing information to a of prescribed antipsychotic medication. The Rationale: The Nurse has a responsibility to electrolytes are necessary for cardiac
community group about violence in the family. most important piece of information the nurse observe continuously the acutely suicidal client. functioning.
Which statement by a group member would in charge should obtain initially is the: The Nurse should watch for clues, such as 15. Answer: B
indicate a need to provide additional a. Length of time on the med. communicating suicidal thoughts, and messages; Rationale: Limiting unnecessary interaction will
information? b. Name of the ingested medication & the hoarding medications and talking about death. decrease stimulation and agitation.
a. “Abuse occurs more in low-income amount ingested 4. Answer: B 16. Answer: C
families” c. Reason for the suicide attempt Rationale: Establishing a consistent eating plan Rationale: Ritualistic behavior seen in this
b. “Abuser Are often jealous or self- d. Name of the nearest relative & their and monitoring client’s weight are important to disorder is aimed at controlling guilt and
centered” phone number this disorder. inadequacy by maintaining an absolute set
c. “Abuser use fear and intimidation” 5. Answer: C pattern of behavior.
d. “Abuser usually have poor self-esteem” Rationale: Appropriate nursing interventions for 17. Answer: D
an anxiety attack include using short sentences, Rationale: The nurse needs to set limits in the
47. During electroconvulsive therapy (ECT) the client staying with the client, decreasing stimuli, client’s manipulative behavior to help the client
receives oxygen by mask via positive pressure remaining calm and medicating as needed. control dysfunctional behavior. A consistent
ventilation. The nurse assisting with this 6. Answer:B approach by the staff is necessary to decrease
procedure knows that positive pressure Rationale: Delusion of grandeur is a false belief manipulation.
ventilation is necessary because? that one is highly famous and important. 18. Answer: B
a. Anesthesia is administered during the 7. Answer: D Rationale: Any suicidal statement must be
procedure Rationale: Individual with dependent personality assessed by the nurse. The nurse should discuss
b. Decrease oxygen to the brain increases disorder typically shows indecisiveness the client’s statement with her to determine its
confusion and disorientation submissiveness and clinging behavior so that meaning in terms of suicide.
c. Grand mal seizure activity depresses others will make decisions with them. 19. Answer: A
respirations 8. Answer: A Rationale: When the staff member ask the client
d. Muscle relaxations given to prevent Rationale: Clients with schizotypal personality if he wonders why others find him repulsive, the
injury during seizure activity depress disorder experience excessive social anxiety that client is likely to feel defensive because the
respirations. can lead to paranoid thoughts question is belittling. The natural tendency is to
9. Answer: B counterattack the threat to self-image.
48. When planning the discharge of a client with Rationale: Bulimia disorder generally is a 20. Answer: B
chronic anxiety, Nurse Chris evaluates maladaptive coping response to stress and Rationale: The nurse would specifically use
achievement of the discharge maintenance underlying issues. The client should identify supportive confrontation with the client to point
goals. Which goal would be most appropriately anxiety causing situation that stimulate the out discrepancies between what the client states
having been included in the plan of care bulimic behavior and then learn new ways of and what actually exists to increase
requiring evaluation? coping with the anxiety. responsibility for self.
a. The client eliminates all anxiety from 10. Answer: A 21. Answer: C
daily situations Rationale: An adult age 31 to 45 generates new Rationale: The nurse would most likely
b. The client ignores feelings of anxiety level of awareness. administer benzodiazepine, such as lorazepan
c. The client identifies anxiety producing 11. Answer: A (ativan) to the client who is experiencing
situations Rationale: Neuromuscular Blocker, such as symptom: The client’s experiences symptoms of
d. The client maintains contact with a crisis SUCCINYLCHOLINE (Anectine) produces withdrawal because of the rebound
counselor respiratory depression because it inhibits phenomenon when the sedation of the CNS
contractions of respiratory muscles. from alcohol begins to decrease.
12. Answer: C 22. Answer: D
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Rationale: Regular coffee contains caffeine Rationale: These are the major signs of anorexia Rationale: Personal characteristics of abuser
which acts as psychomotor stimulants and leads nervosa. Weight loss is excessive (15% of include low self-esteem, immaturity,
to feelings of anxiety and agitation. Serving expected weight) dependence, insecurity and jealousy.
coffee top the client may add to tremors or 35. Answer: C 47. Answer: D
wakefulness. Rationale: Dental enamel erosion occurs from Rationale: A short acting skeletal muscle relaxant
23. Answer: D repeated self-induced vomiting. such as succinylcholine (Anectine) is
Rationale: Vomiting and diarrhea are usually the 36. Answer: B administered during this procedure to prevent
late signs of heroin withdrawal, along with Rationale: Depression usually is both emotional injuries during seizure.
muscle spasm, fever, nausea, repetitive, & physical. A simple daily routine is the best, 48. Answer: C
abdominal cramps and backache. least stressful and least anxiety producing. Rationale: Recognizing situations that produce
24. Answer: D 37. Answer: D anxiety allows the client to prepare to cope with
Rationale: Moving to a client’s personal space Rationale: The expression of these feeling may anxiety or avoid specific stimulus.
increases the feeling of threat, which increases indicate that this client is unable to continue the 49. Answer: D
anxiety. struggle of life. Rationale: Electroconvulsive therapy is an
25. Answer: A 38. Answer: A effective treatment for depression that has not
Rationale: Environmental (MILIEU) therapy aims Rationale: Structure tends to decrease agitation responded to medication
at having everything in the client’s surrounding and anxiety and to increase the client’s feeling of 50. Answer: B
area toward helping the client. security. Rationale: In an emergency, lives saving facts are
26. Answer: C 39. Answer: B obtained first. The name and the amount of
Rationale: Children who have experienced Rationale: The rituals used by a client with medication ingested are of outmost important in
attachment difficulties with primary caregiver obsessive compulsive disorder help control the treating this potentially life threatening
are not able to trust others and therefore relate anxiety level by maintaining a set pattern of situation.
superficially action.
27. Answer: A 40. Answer: C
Rationale: Children have difficulty verbally Rationale: A person with this disorder would not
expressing their feelings, acting out behavior, have adequate self-boundaries
such as temper tantrums, may indicate 41. Answer: D
underlying depression. Rationale: Loose associations are thoughts that
28. Answer: D are presented without the logical connections
Rationale: The autistic child repeats sounds or usually necessary for the listening to interpret
words spoken by others. the message.
29. Answer: D 42. Answer: C
Rationale: The client statement is an example of Rationale: Helping the client to develop feeling
the use of denial, a defense that blocks problem of self-worth would reduce the client’s need to
by unconscious refusing to admit they exist use pathologic defenses.
30. Answer: A 43. Answer: B
Rationale: Discussion of the feared object Rationale: Open ended questions and silence are
triggers an emotional response to the object. strategies used to encourage clients to discuss
31. Answer: B their problem in descriptive manner.
Rationale: The nurse presence may provide the 44. Answer: C
client with support & feeling of control. Rationale: Clients who are withdrawn may be
32. Answer: D immobile and mute, and require consistent,
Rationale: Experiencing the actual trauma in repeated interventions. Communication with
dreams or flashback is the major symptom that withdrawn clients requires much patience from
distinguishes post-traumatic stress disorder from the nurse. The nurse facilitates communication
other anxiety disorder. with the client by sitting in silence, asking open-
33. Answer: C ended question and pausing to provide
Rationale: Confabulation or the filling in of opportunities for the client to respond.
memory gaps with imaginary facts is a defense 45. Answer: D
mechanism used by people experiencing Rationale: When hallucination is present, the
memory deficits. nurse should reinforce reality with the client.
34. Answer: A 46. Answer: A
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FUNDAMENTALS OF NURSING PART 1 a. Keep unnecessary furniture out of the 15. It is a transparent membrane that focuses the d. Dr.
way light that enters the eyes to the retina. 24. The abbreviation for micro drop is…
1. Using the principles of standard precautions, the b. Keep the lights on at all time a. Lens a. µgtt
nurse would wear gloves in what nursing c. Keep side rails up at all time b. Sclera b. gtt
interventions? d. Keep all equipment out of view c. Cornea c. mdr
a. Providing a back massage 8. A walk-in client enters into the clinic with a chief d. Pupils d. mgts
b. Feeding a client complaint of abdominal pain and diarrhea. The 16. Which of the following is included in Orem’s 25. Which of the following is the meaning of PRN?
c. Providing hair care nurse takes the client’s vital sign hereafter. What theory? a. When advice
d. Providing oral hygiene phrase of nursing process is being implemented a. Maintenance of a sufficient intake of air b. Immediately
2. The nurse is preparing to take vital sign in an here by the nurse? b. Self perception c. When necessary
alert client admitted to the hospital with a. Assessment c. Love and belonging d. Now
dehydration secondary to vomiting and diarrhea. b. Diagnosis d. Physiologic needs 26. Which of the following is the appropriate
What is the best method used to assess the c. Planning 17. Which of the following cluster of data belong to meaning of CBR?
client’s temperature? d. Implementation Maslow’s hierarchy of needs a. Cardiac Board Room
a. Oral 9. It is best describe as a systematic, rational a. Love and belonging b. Complete Bathroom
b. Axillary method of planning and providing nursing care b. Physiologic needs c. Complete Bed Rest
c. Radial for individual, families, group and community c. Self actualization d. Complete Board Room
d. Heat sensitive tape a. Assessment d. All of the above 27. 1 tsp is equals to how many drops?
3. A nurse obtained a client’s pulse and found the b. Nursing Process 18. This is characterized by severe symptoms a. 15
rate to be above normal. The nurse document c. Diagnosis relatively of short duration. b. 60
this findings as: d. Implementation a. Chronic Illness c. 10
a. Tachypnea 10. Exchange of gases takes place in which of the b. Acute Illness d. 30
b. Hyper pyrexia following organ? c. Pain 28. 20 cc is equal to how many ml?
c. Arrythmia a. Kidney d. Syndrome a. 2
d. Tachycardia b. Lungs 19. Which of the following is the nurse’s role in the b. 20
4. Which of the following actions should the nurse c. Liver health promotion c. 2000
take to use a wide base support when assisting a d. Heart a. Health risk appraisal d. 20000
client to get up in a chair? 11. The Chamber of the heart that receives b. Teach client to be effective health 29. 1 cup is equal to how many ounces?
a. Bend at the waist and place arms under oxygenated blood from the lungs is the? consumer a. 8
the client’s arms and lift a. Left atrium c. Worksite wellness b. 80
b. Face the client, bend knees and place b. Right atrium d. None of the above c. 800
hands on client’s forearm and lift c. Left ventricle 20. It is describe as a collection of people who share d. 8000
c. Spread his or her feet apart d. Right ventricle some attributes of their lives. 30. The nurse must verify the client’s identity before
d. Tighten his or her pelvic muscles 12. A muscular enlarge pouch or sac that lies slightly a. Family administration of medication. Which of the
5. A client had oral surgery following a motor to the left which is used for temporary storage b. Illness following is the safest way to identify the client?
vehicle accident. The nurse assessing the client of food… c. Community a. Ask the client his name
finds the skin flushed and warm. Which of the a. Gallbladder d. Nursing b. Check the client’s identification band
following would be the best method to take the b. Urinary bladder 21. Five teaspoon is equivalent to how many c. State the client’s name aloud and have
client’s body temperature? c. Stomach milliliters (ml)? the client repeat it
a. Oral d. Lungs a. 30 ml d. Check the room number
b. Axillary 13. The ability of the body to defend itself against b. 25 ml 31. The nurse prepares to administer buccal
c. Arterial line scientific invading agent such as baceria, toxin, c. 12 ml medication. The medicine should be placed…
d. Rectal viruses and foreign body d. 75 ml a. On the client’s skin
6. A client who is unconscious needs frequent a. Hormones 22. 1800 ml is equal to how many liters? b. Between the client’s cheeks and gums
mouth care. When performing a mouth care, the b. Secretion a. 1.8 c. Under the client’s tongue
best position of a client is: c. Immunity b. 18000 d. On the client’s conjuctiva
a. Fowler’s position d. Glands c. 180 32. The nurse administers cleansing enema. The
b. Side lying 14. Hormones secreted by Islets of Langerhans d. 2800 common position for this procedure is…
c. Supine a. Progesterone 23. Which of the following is the abbreviation of a. Sims left lateral
d. Trendelenburg b. Testosterone drops? b. Dorsal Recumbent
7. A client is hospitalized for the first time, which of c. Insulin a. Gtt. c. Supine
the following actions ensure the safety of the d. Hemoglobin b. Gtts. d. Prone
client? c. Dp.
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33. A client complains of difficulty of swallowing, a. To cleanse, refresh and give comfort to a. Genu-dorsal
when the nurse try to administer capsule the client who must remain in bed b. Genu-pectoral
medication. Which of the following measures b. To expose the necessary parts of the c. Lithotomy
the nurse should do? body d. Sim’s
a. Dissolve the capsule in a glass of water c. To develop skills in bed bath 50. The nurse prepares IM injection that is irritating
b. Break the capsule and give the content d. To check the body temperature of the to the subcutaneous tissue. Which of the
with an applesauce client in bed following is the best action in order to prevent
c. Check the availability of a liquid 41. Which of the following technique involves the tracking of the medication
preparation sense of sight? a. Use a small gauge needle
d. Crash the capsule and place it under the a. Inspection b. Apply ice on the injection site
tongue b. Palpation c. Administer at a 45° angle
34. Which of the following is the appropriate route c. Percussion d. Use the Z-track technique
of administration for insulin? d. Auscultation
a. Intramuscular 42. The first techniques used examining the
b. Intradermal abdomen of a client is:
c. Subcutaneous a. Palpation
d. Intravenous b. Auscultation
35. The nurse is ordered to administer ampicillin c. Percussion
capsule TIP p.o. The nurse shoud give the d. Inspection
medication… 43. A technique in physical examination that is use
a. Three times a day orally to assess the movement of air through the
b. Three times a day after meals tracheobronchial tree:
c. Two time a day by mouth a. Palpation
d. Two times a day before meals b. Auscultation
36. Back Care is best describe as: c. Inspection
a. Caring for the back by means of massage d. Percussion
b. Washing of the back 44. An instrument used for auscultation is:
c. Application of cold compress at the back a. Percussion-hammer
d. Application of hot compress at the back b. Audiometer
37. It refers to the preparation of the bed with a c. Stethoscope
new set of linens d. Sphygmomanometer
a. Bed bath 45. Resonance is best describe as:
b. Bed making a. Sounds created by air filled lungs
c. Bed shampoo b. Short, high pitch and thudding
d. Bed lining c. Moderately loud with musical quality
38. Which of the following is the most important d. Drum-like
purpose of handwashing 46. The best position for examining the rectum is:
a. To promote hand circulation a. Prone
b. To prevent the transfer of b. Sim’s
microorganism c. Knee-chest
c. To avoid touching the client with a dirty d. Lithotomy
hand 47. It refers to the manner of walking
d. To provide comfort a. Gait
39. What should be done in order to prevent b. Range of motion
contaminating of the environment in bed c. Flexion and extension
making? d. Hopping
a. Avoid funning soiled linens 48. The nurse asked the client to read the Snellen
b. Strip all linens at the same time chart. Which of the following is tested:
c. Finished both sides at the time a. Optic
d. Embrace soiled linen b. Olfactory
40. The most important purpose of cleansing bed c. Oculomotor
bath is: d. Troclear
49. Another name for knee-chest position is:
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6. The four main concepts common to nursing that
appear in each of the current conceptual models
FUNDAMENTALS OF NURSING PART 2 are:
391
a. Person, nursing, environment, medicine
1. The most appropriate nursing order for a patient b. Person, health, nursing, support systems
1.d 11.a 21.b 31.b 41.a who develops dyspnea and shortness of breath c. Person, health, psychology, nursing
would be… d. Person, environment, health, nursing
2.b 12.c 22.a 32.a 42.d
a. Maintain the patient on strict bed rest at 7. In Maslow’s hierarchy of physiologic needs, the
3.d 13.c 23.b 33.c 43.b all times human need of greatest priority is:
4 b 14.c 24.a 34.c 44.c b. Maintain the patient in an orthopneic a. Love
position as needed b. Elimination
5.b 15.c 25.c 35.a 45.a
c. Administer oxygen by Venturi mask at c. Nutrition
6.b 16.a 26.c 36.a 46.c 24%, as needed d. Oxygen
7.c 17.d 27.b 37.b 47.a d. Allow a 1 hour rest period between 8. The family of an accident victim who has been
activities declared brain-dead seems amenable to organ
8.a 18.b 28.b 38.b 48.a
2. The nurse observes that Mr. Adams begins to donation. What should the nurse do?
9.b 19.b 29.a 39.a 49.b have increased difficulty breathing. She elevates a. Discourage them from making a decision
10.b 20.c 30.a 40.a 50.d the head of the bed to the high Fowler position, until their grief has eased
which decreases his respiratory distress. The b. Listen to their concerns and answer their
nurse documents this breathing as: questions honestly
a. Tachypnea c. Encourage them to sign the consent
b. Eupnca form right away
c. Orthopnea d. Tell them the body will not be available
d. Hyperventilation for a wake or funeral
3. The physician orders a platelet count to be 9. A new head nurse on a unit is distressed about
performed on Mrs. Smith after breakfast. The the poor staffing on the 11 p.m. to 7 a.m. shift.
nurse is responsible for: What should she do?
a. Instructing the patient about this a. Complain to her fellow nurses
diagnostic test b. Wait until she knows more about the
b. Writing the order for this test unit
c. Giving the patient breakfast c. Discuss the problem with her supervisor
d. All of the above d. Inform the staff that they must
4. Mrs. Mitchell has been given a copy of her diet. volunteer to rotate
The nurse discusses the foods allowed on a 500- 10. Which of the following principles of primary
mg low sodium diet. These include: nursing has proven the most satisfying to the
a. A ham and Swiss cheese sandwich on patient and nurse?
whole wheat bread a. Continuity of patient care promotes
b. Mashed potatoes and broiled chicken efficient, cost-effective nursing care
c. A tossed salad with oil and vinegar and b. Autonomy and authority for planning
olives are best delegated to a nurse who
d. Chicken bouillon knows the patient well
5. The physician orders a maintenance dose of c. Accountability is clearest when one
5,000 units of subcutaneous heparin (an nurse is responsible for the overall plan
anticoagulant) daily. Nursing responsibilities for and its implementation.
Mrs. Mitchell now include: d. The holistic approach provides for a
a. Reviewing daily activated partial therapeutic relationship, continuity, and
thromboplastin time (APTT) and efficient nursing care.
prothrombin time. 11. If nurse administers an injection to a patient
b. Reporting an APTT above 45 seconds to who refuses that injection, she has committed:
the physician a. Assault and battery
c. Assessing the patient for signs and b. Negligence
symptoms of frank and occult bleeding c. Malpractice
d. All of the above
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d. None of the above would immediately alert the nurse that the c. Anxiety following nursing diagnosis: Impaired gas
12. If patient asks the nurse her opinion about a patient has bleeding from the GI tract? d. Dehydration exchange related to increased secretions. Which
particular physicians and the nurse replies that a. Complete blood count 24. Which of the following parameters should be of the following nursing interventions has the
the physician is incompetent, the nurse could be b. Guaiac test checked when assessing respirations? greatest potential for improving this situation?
held liable for: c. Vital signs a. Rate a. Encourage the patient to increase her
a. Slander d. Abdominal girth b. Rhythm fluid intake to 200 ml every 2 hours
b. Libel 17. The correct sequence for assessing the abdomen c. Symmetry b. Place a humidifier in the patient’s room.
c. Assault is: d. All of the above c. Continue administering oxygen by high
d. Respondent superior a. Tympanic percussion, measurement of 25. A 38-year old patient’s vital signs at 8 a.m. are humidity face mask
13. A registered nurse reaches to answer the abdominal girth, and inspection axillary temperature 99.6 F (37.6 C); pulse rate, d. Perform chest physiotheraphy on a
telephone on a busy pediatric unit, momentarily b. Assessment for distention, tenderness, 88; respiratory rate, 30. Which findings should regular schedule
turning away from a 3 month-old infant she has and discoloration around the umbilicus. be reported? 31. The most common deficiency seen in alcoholics
been weighing. The infant falls off the scale, c. Percussions, palpation, and auscultation a. Respiratory rate only is:
suffering a skull fracture. The nurse could be d. Auscultation, percussion, and palpation b. Temperature only a. Thiamine
charged with: 18. High-pitched gurgles head over the right lower c. Pulse rate and temperature b. Riboflavin
a. Defamation quadrant are: d. Temperature and respiratory rate c. Pyridoxine
b. Assault a. A sign of increased bowel motility 26. All of the following can cause tachycardia d. Pantothenic acid
c. Battery b. A sign of decreased bowel motility except: 32. Which of the following statement is incorrect
d. Malpractice c. Normal bowel sounds a. Fever about a patient with dysphagia?
14. Which of the following is an example of nursing d. A sign of abdominal cramping b. Exercise a. The patient will find pureed or soft
malpractice? 19. A patient about to undergo abdominal c. Sympathetic nervous system stimulation foods, such as custards, easier to
a. The nurse administers penicillin to a inspection is best placed in which of the d. Parasympathetic nervous system swallow than water
patient with a documented history of following positions? stimulation b. Fowler’s or semi Fowler’s position
allergy to the drug. The patient a. Prone 27. Palpating the midclavicular line is the correct reduces the risk of aspiration during
experiences an allergic reaction and has b. Trendelenburg technique for assessing swallowing
cerebral damage resulting from anoxia. c. Supine a. Baseline vital signs c. The patient should always feed himself
b. The nurse applies a hot water bottle or a d. Side-lying b. Systolic blood pressure d. The nurse should perform oral hygiene
heating pad to the abdomen of a patient 20. For a rectal examination, the patient can be c. Respiratory rate before assisting with feeding.
with abdominal cramping. directed to assume which of the following d. Apical pulse 33. To assess the kidney function of a patient with
c. The nurse assists a patient out of bed positions? 28. The absence of which pulse may not be a an indwelling urinary (Foley) catheter, the nurse
with the bed locked in position; the a. Genupecterol significant finding when a patient is admitted to measures his hourly urine output. She should
patient slips and fractures his right b. Sims the hospital? notify the physician if the urine output is:
humerus. c. Horizontal recumbent a. Apical a. Less than 30 ml/hour
d. The nurse administers the wrong d. All of the above b. Radial b. 64 ml in 2 hours
medication to a patient and the patient 21. During a Romberg test, the nurse asks the c. Pedal c. 90 ml in 3 hours
vomits. This information is documented patient to assume which position? d. Femoral d. 125 ml in 4 hours
and reported to the physician and the a. Sitting 29. Which of the following patients is at greatest risk 34. Certain substances increase the amount of urine
nursing supervisor. b. Standing for developing pressure ulcers? produced. These include:
15. Which of the following signs and symptoms c. Genupectoral a. An alert, chronic arthritic patient treated a. Caffeine-containing drinks, such as
would the nurse expect to find when assessing d. Trendelenburg with steroids and aspirin coffee and cola.
an Asian patient for postoperative pain following 22. If a patient’s blood pressure is 150/96, his pulse b. An 88-year old incontinent patient with b. Beets
abdominal surgery? pressure is: gastric cancer who is confined to his bed c. Urinary analgesics
a. Decreased blood pressure and heart rate a. 54 at home d. Kaolin with pectin (Kaopectate)
and shallow respirations b. 96 c. An apathetic 63-year old COPD patient 35. A male patient who had surgery 2 days ago for
b. Quiet crying c. 150 receiving nasal oxygen via cannula head and neck cancer is about to make his first
c. Immobility, diaphoresis, and avoidance d. 246 d. A confused 78-year old patient with attempt to ambulate outside his room. The
of deep breathing or coughing 23. A patient is kept off food and fluids for 10 hours congestive heart failure (CHF) who nurse notes that he is steady on his feet and that
d. Changing position every 2 hours before surgery. His oral temperature at 8 a.m. is requires assistance to get out of bed. his vision was unaffected by the surgery. Which
16. A patient is admitted to the hospital with 99.8 F (37.7 C) This temperature reading 30. The physician orders the administration of high- of the following nursing interventions would be
complaints of nausea, vomiting, diarrhea, and probably indicates: humidity oxygen by face mask and placement of appropriate?
severe abdominal pain. Which of the following a. Infection the patient in a high Fowler’s position. After a. Encourage the patient to walk in the hall
b. Hypothermia assessing Mrs. Paul, the nurse writes the alone
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b. Discourage the patient from walking in a. Asses the patient’s ability to ambulate d. Alzheimer’s disease
the hall for a few more days and transfer from a bed to a chair 48. The nurse’s most important legal responsibility
c. Accompany the patient for his walk. b. Demonstrate the signal system to the after a patient’s death in a hospital is:
d. Consuit a physical therapist before patient a. Obtaining a consent of an autopsy
allowing the patient to ambulate c. Check to see that the patient is wearing b. Notifying the coroner or medical
36. A patient has exacerbation of chronic his identification band examiner
obstructive pulmonary disease (COPD) d. All of the above c. Labeling the corpse appropriately
manifested by shortness of breath; orthopnea: 42. Studies have shown that about 40% of patients d. Ensuring that the attending physician
thick, tenacious secretions; and a dry hacking fall out of bed despite the use of side rails; this issues the death certification
cough. An appropriate nursing diagnosis would has led to which of the following conclusions? 49. Before rigor mortis occurs, the nurse is
be: a. Side rails are ineffective responsible for:
a. Ineffective airway clearance related to b. Side rails should not be used a. Providing a complete bath and dressing
thick, tenacious secretions. c. Side rails are a deterrent that prevent a change
b. Ineffective airway clearance related to patient from falling out of bed. b. Placing one pillow under the body’s
dry, hacking cough. d. Side rails are a reminder to a patient not head and shoulders
c. Ineffective individual coping to COPD. to get out of bed c. Removing the body’s clothing and
d. Pain related to immobilization of 43. Examples of patients suffering from impaired wrapping the body in a shroud
affected leg. awareness include all of the following except: d. Allowing the body to relax normally
37. Mrs. Lim begins to cry as the nurse discusses hair a. A semiconscious or over fatigued patient 50. When a patient in the terminal stages of lung
loss. The best response would be: b. A disoriented or confused patient cancer begins to exhibit loss of consciousness, a
a. “Don’t worry. It’s only temporary” c. A patient who cannot care for himself at major nursing priority is to:
b. “Why are you crying? I didn’t get to the home a. Protect the patient from injury
bad news yet” d. A patient demonstrating symptoms of b. Insert an airway
c. “Your hair is really pretty” drugs or alcohol withdrawal c. Elevate the head of the bed
d. “I know this will be difficult for you, but 44. The most common injury among elderly persons d. Withdraw all pain medications
your hair will grow back after the is:
completion of chemotheraphy” a. Atheroscleotic changes in the blood
38. An additional Vitamin C is required during all of vessels
the following periods except: b. Increased incidence of gallbladder
a. Infancy disease
b. Young adulthood c. Urinary Tract Infection
c. Childhood d. Hip fracture
d. Pregnancy 45. The most common psychogenic disorder among
39. A prescribed amount of oxygen s needed for a elderly person is:
patient with COPD to prevent: a. Depression
a. Cardiac arrest related to increased b. Sleep disturbances (such as bizarre
partial pressure of carbon dioxide in dreams)
arterial blood (PaCO2) c. Inability to concentrate
b. Circulatory overload due to d. Decreased appetite
hypervolemia 46. Which of the following vascular system changes
c. Respiratory excitement results from aging?
d. Inhibition of the respiratory hypoxic a. Increased peripheral resistance of the
stimulus blood vessels
40. After 1 week of hospitalization, Mr. Gray b. Decreased blood flow
develops hypokalemia. Which of the following is c. Increased work load of the left ventricle
the most significant symptom of his disorder? d. All of the above
a. Lethargy 47. Which of the following is the most common
b. Increased pulse rate and blood pressure cause of dementia among elderly persons?
c. Muscle weakness a. Parkinson’s disease
d. Muscle irritability b. Multiple sclerosis
41. Which of the following nursing interventions c. Amyotrophic lateral sclerosis (Lou
promotes patient safety? Gerhig’s disease)
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ANSWERS and RATIONALES for FUNDAMENTALS OF continuum, and the nursing actions necessary to breached; a 3-month-old infant should never be cramping with hyperactive, high pitched tinkling
NURSING PART 2 meet his needs. left unattended on a scale. bowel sounds can indicate a bowel obstruction.
7. D. Maslow, who defined a need as a satisfaction 14. A. The three elements necessary to establish a 19. C. The supine position (also called the dorsal
1. B. When a patient develops dyspnea and whose absence causes illness, considered nursing malpractice are nursing error position), in which the patient lies on his back
shortness of breath, the orthopneic position oxygen to be the most important physiologic (administering penicillin to a patient with a with his face upward, allows for easy access to
encourages maximum chest expansion and need; without it, human life could not exist. documented allergy to the drug), injury (cerebral the abdomen. In the prone position, the patient
keeps the abdominal organs from pressing According to this theory, other physiologic needs damage), and proximal cause (administering the lies on his abdomen with his face turned to the
against the diaphragm, thus improving (including food, water, elimination, shelter, rest penicillin caused the cerebral damage). Applying side. In the Trendelenburg position, the head of
ventilation. Bed rest and oxygen by Venturi mask and sleep, activity and temperature regulation) a hot water bottle or heating pad to a patient the bed is tilted downward to 30 to 40 degrees
at 24% would improve oxygenation of the must be met before proceeding to the next without a physician’s order does not include the so that the upper body is lower than the legs. In
tissues and cells but must be ordered by a hierarchical levels on psychosocial needs. three required components. Assisting a patient the lateral position, the patient lies on his side.
physician. Allowing for rest periods decreases 8. B. The brain-dead patient’s family needs support out of bed with the bed locked in position is the 20. D. All of these positions are appropriate for a
the possibility of hypoxia. and reassurance in making a decision about correct nursing practice; therefore, the fracture rectal examination. In the genupectoral (knee-
2. C. Orthopnea is difficulty of breathing except in organ donation. Because transplants are done was not the result of malpractice. Administering chest) position, the patient kneels and rests his
the upright position. Tachypnea is rapid within hours of death, decisions about organ an incorrect medication is a nursing error; chest on the table, forming a 90 degree angle
respiration characterized by quick, shallow donation must be made as soon as possible. however, if such action resulted in a serious between the torso and upper legs. In Sims’
breaths. Eupnea is normal respiration – quiet, However, the family’s concerns must be illness or chronic problem, the nurse could be position, the patient lies on his left side with the
rhythmic, and without effort. addressed before members are asked to sign a sued for malpractice. left arm behind the body and his right leg flexed.
3. C. A platelet count evaluates the number of consent form. The body of an organ donor is 15. C. An Asian patient is likely to hide his pain. In the horizontal recumbent position, the patient
platelets in the circulating blood volume. The available for burial. Consequently, the nurse must observe for lies on his back with legs extended and hips
nurse is responsible for giving the patient 9. C. Although a new head nurse should initially objective signs. In an abdominal surgery patient, rotated outward.
breakfast at the scheduled time. The physician is spend time observing the unit for its strengths these might include immobility, diaphoresis, and 21. B. During a Romberg test, which evaluates for
responsible for instructing the patient about the and weakness, she should take action if a avoidance of deep breathing or coughing, as well sensory or cerebellar ataxia, the patient must
test and for writing the order for the test. problem threatens patient safety. In this case, as increased heart rate, shallow respirations stand with feet together and arms resting at the
4. B. Mashed potatoes and broiled chicken are low the supervisor is the resource person to (stemming from pain upon moving the sides—first with eyes open, then with eyes
in natural sodium chloride. Ham, olives, and approach. diaphragm and respiratory muscles), and closed. The need to move the feet apart to
chicken bouillon contain large amounts of 10. D. Studies have shown that patients and nurses guarding or rigidity of the abdominal wall. Such a maintain this stance is an abnormal finding.
sodium and are contraindicated on a low sodium both respond well to primary nursing care units. patient is unlikely to display emotion, such as 22. A. The pulse pressure is the difference between
diet. Patients feel less anxious and isolated and more crying. the systolic and diastolic blood pressure readings
5. D. All of the identified nursing responsibilities secure because they are allowed to participate 16. B. To assess for GI tract bleeding when frank – in this case, 54.
are pertinent when a patient is receiving in planning their own care. Nurses feel personal blood is absent, the nurse has two options: She 23. D. A slightly elevated temperature in the
heparin. The normal activated partial satisfaction, much of it related to positive can test for occult blood in vomitus, if present, immediate preoperative or post operative
thromboplastin time is 16 to 25 seconds and the feedback from the patients. They also seem to or in stool – through guaiac (Hemoccult) test. A period may result from the lack of fluids before
normal prothrombin time is 12 to 15 seconds; gain a greater sense of achievement and esprit complete blood count does not provide surgery rather than from infection. Anxiety will
these levels must remain within two to two and de corps. immediate results and does not always not cause an elevated temperature.
one half the normal levels. All patients receiving 11. A. Assault is the unjustifiable attempt or threat immediately reflect blood loss. Changes in vital Hypothermia is an abnormally low body
anticoagulant therapy must be observed for to touch or injure another person. Battery is the signs may be cause by factors other than blood temperature.
signs and symptoms of frank and occult bleeding unlawful touching of another person or the loss. Abdominal girth is unrelated to blood loss. 24. D. The quality and efficiency of the respiratory
(including hemorrhage, hypotension, carrying out of threatened physical harm. Thus, 17. D. Because percussion and palpation can affect process can be determined by appraising the
tachycardia, tachypnea, restlessness, pallor, cold any act that a nurse performs on the patient bowel motility and thus bowel sounds, they rate, rhythm, depth, ease, sound, and symmetry
and clammy skin, thirst and confusion); blood against his will is considered assault and battery. should follow auscultation in abdominal of respirations.
pressure should be measured every 4 hours and 12. A. Oral communication that injures an assessment. Tympanic percussion, measurement 25. D. Under normal conditions, a healthy adult
the patient should be instructed to report individual’s reputation is considered slander. of abdominal girth, and inspection are methods breathes in a smooth uninterrupted pattern 12
promptly any bleeding that occurs with tooth Written communication that does the same is of assessing the abdomen. Assessing for to 20 times a minute. Thus, a respiratory rate of
brushing, bowel movements, urination or heavy considered libel. distention, tenderness and discoloration around 30 would be abnormal. A normal adult body
prolonged menstruation. 13. D. Malpractice is defined as injurious or the umbilicus can indicate various bowel-related temperature, as measured on an oral
6. D. The focus concepts that have been accepted unprofessional actions that harm another. It conditions, such as cholecystitis, appendicitis thermometer, ranges between 97° and 100°F
by all theorists as the focus of nursing practice involves professional misconduct, such as and peritonitis. (36.1° and 37.8°C); an axillary temperature is
from the time of Florence Nightingale include omission or commission of an act that a 18. C. Hyperactive sounds indicate increased bowel approximately one degree lower and a rectal
the person receiving nursing care, his reasonable and prudent nurse would or would motility; two or three sounds per minute temperature, one degree higher. Thus, an
environment, his health on the health illness not do. In this example, the standard of care was indicate decreased bowel motility. Abdominal axillary temperature of 99.6°F (37.6°C) would be
considered abnormal. The resting pulse rate in
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an adult ranges from 60 to 100 beats/minute, so 34. A. Fluids containing caffeine have a diuretic 40. C. Presenting symptoms of hypokalemia ( a unknown. Parkinson’s disease is a neurologic
a rate of 88 is normal. effect. Beets and urinary analgesics, such as serum potassium level below 3.5 mEq/liter) disorder caused by lesions in the extrapyramidial
26. D. Parasympathetic nervous system stimulation pyridium, can color urine red. Kaopectate is an include muscle weakness, chronic fatigue, and system and manifested by tremors, muscle
of the heart decreases the heart rate as well as anti diarrheal medication. cardiac dysrhythmias. The combined effects of rigidity, hypokinesis, dysphagia, and dysphonia.
the force of contraction, rate of impulse 35. C. A hospitalized surgical patient leaving his inadequate food intake and prolonged diarrhea Multiple sclerosis, a progressive, degenerative
conduction and blood flow through the coronary room for the first time fears rejection and others can deplete the potassium stores of a patient disease involving demyelination of the nerve
vessels. Fever, exercise, and sympathetic staring at him, so he should not walk alone. with GI problems. fibers, usually begins in young adulthood and is
stimulation all increase the heart rate. Accompanying him will offer moral support, 41. D. Assisting a patient with ambulation and marked by periods of remission and
27. D. The apical pulse (the pulse at the apex of the enabling him to face the rest of the world. transfer from a bed to a chair allows the nurse to exacerbation. Amyotrophic lateral sclerosis, a
heart) is located on the midclavicular line at the Patients should begin ambulation as soon as evaluate the patient’s ability to carry out these disease marked by progressive degeneration of
fourth, fifth, or sixth intercostal space. Base line possible after surgery to decrease complications functions safely. Demonstrating the signal the neurons, eventually results in atrophy of all
vital signs include pulse rate, temperature, and to regain strength and confidence. Waiting system and providing an opportunity for a return the muscles; including those necessary for
respiratory rate, and blood pressure. Blood to consult a physical therapist is unnecessary. demonstration ensures that the patient knows respiration.
pressure is typically assessed at the antecubital 36. A. Thick, tenacious secretions, a dry, hacking how to operate the equipment and encourages 48. C. The nurse is legally responsible for labeling
fossa, and respiratory rate is assessed best by cough, orthopnea, and shortness of breath are him to call for assistance when needed. Checking the corpse when death occurs in the hospital.
observing chest movement with each inspiration signs of ineffective airway clearance. Ineffective the patient’s identification band verifies the She may be involved in obtaining consent for an
and expiration. airway clearance related to dry, hacking cough is patient’s identity and prevents identification autopsy or notifying the coroner or medical
28. C. Because the pedal pulse cannot be detected incorrect because the cough is not the reason for mistakes in drug administration. examiner of a patient’s death; however, she is
in 10% to 20% of the population, its absence is the ineffective airway clearance. Ineffective 42. D. Since about 40% of patients fall out of bed not legally responsible for performing these
not necessarily a significant finding. However, individual coping related to COPD is wrong despite the use of side rails, side rails cannot be functions. The attending physician may need
the presence or absence of the pedal pulse because the etiology for a nursing diagnosis said to prevent falls; however, they do serve as a information from the nurse to complete the
should be documented upon admission so that should not be a medical diagnosis (COPD) and reminder that the patient should not get out of death certificate, but he is responsible for issuing
changes can be identified during the hospital because no data indicate that the patient is bed. The other answers are incorrect it.
stay. Absence of the apical, radial, or femoral coping ineffectively. Pain related to interpretations of the statistical data. 49. B. The nurse must place a pillow under the
pulse is abnormal and should be investigated. immobilization of affected leg would be an 43. C. A patient who cannot care for himself at decreased person’s head and shoulders to
29. B. Pressure ulcers are most likely to develop in appropriate nursing diagnosis for a patient with home does not necessarily have impaired prevent blood from settling in the face and
patients with impaired mental status, mobility, a leg fracture. awareness; he may simply have some degree of discoloring it. She is required to bathe only
activity level, nutrition, circulation and bladder 37. D. “I know this will be difficult” acknowledges immobility. soiled areas of the body since the mortician will
or bowel control. Age is also a factor. Thus, the the problem and suggests a resolution to it. 44. D. Hip fracture, the most common injury among wash the entire body. Before wrapping the body
88-year old incontinent patient who has “Don’t worry..” offers some relief but doesn’t elderly persons, usually results from in a shroud, the nurse places a clean gown on
impaired nutrition (from gastric cancer) and is recognize the patient’s feelings. “..I didn’t get to osteoporosis. The other answers are diseases the body and closes the eyes and mouth.
confined to bed is at greater risk. the bad news yet” would be inappropriate at any that can occur in the elderly from physiologic 50. A. Ensuring the patient’s safety is the most
30. A. Adequate hydration thins and loosens time. “Your hair is really pretty” offers no changes. essential action at this time. The other nursing
pulmonary secretions and also helps to replace consolation or alternatives to the patient. 45. A. Sleep disturbances, inability to concentrate actions may be necessary but are not a major
fluids lost from elevated temperature, 38. B. Additional Vitamin C is needed in growth and decreased appetite are symptoms of priority.
diaphoresis, dehydration and dyspnea. High- periods, such as infancy and childhood, and depression, the most common psychogenic
humidity air and chest physiotherapy help during pregnancy to supply demands for fetal disorder among elderly persons. Other
liquefy and mobilize secretions. growth and maternal tissues. Other conditions symptoms include diminished memory, apathy,
31. A. Chronic alcoholism commonly results in requiring extra vitamin C include wound healing, disinterest in appearance, withdrawal, and
thiamine deficiency and other symptoms of fever, infection and stress. irritability. Depression typically begins before the
malnutrition. 39. D. Delivery of more than 2 liters of oxygen per onset of old age and usually is caused by
32. C. A patient with dysphagia (difficulty minute to a patient with chronic obstructive psychosocial, genetic, or biochemical factors
swallowing) requires assistance with feeding. pulmonary disease (COPD), who is usually in a 46. D. Aging decreases elasticity of the blood
Feeding himself is a long-range expected state of compensated respiratory acidosis vessels, which leads to increased peripheral
outcome. Soft foods, Fowler’s or semi-Fowler’s (retaining carbon dioxide (CO2)), can inhibit the resistance and decreased blood flow. These
position, and oral hygiene before eating should hypoxic stimulus for respiration. An increased changes, in turn, increase the work load of the
be part of the feeding regimen. partial pressure of carbon dioxide in arterial left ventricle.
33. A. A urine output of less than 30ml/hour blood (PACO2) would not initially result in 47. D. Alzheimer;s disease, sometimes known as
indicates hypovolemia or oliguria, which is cardiac arrest. Circulatory overload and senile dementia of the Alzheimer’s type or
related to kidney function and inadequate fluid respiratory excitement have no relevance to the primary degenerative dementia, is an insidious;
intake. question. progressive, irreversible, and degenerative
disease of the brain whose etiology is still
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FUNDAMENTALS OF NURSING PART 3 8. Which of the following constitutes a break in b. Using a water or air mattress the patient’s skin. The most appropriate nursing
sterile technique while preparing a sterile field c. Adhering to a schedule for positioning action would be to:
1. Which element in the circular chain of infection for a dressing change? and turning a. Withhold the moderation and notify the
can be eliminated by preserving skin integrity? a. Using sterile forceps, rather than sterile d. Providing meticulous skin care physician
a. Host gloves, to handle a sterile item 14. Which of the following blood tests should be b. Administer the medication and notify
b. Reservoir b. Touching the outside wrapper of performed before a blood transfusion? the physician
c. Mode of transmission sterilized material without sterile gloves a. Prothrombin and coagulation time c. Administer the medication with an
d. Portal of entry c. Placing a sterile object on the edge of b. Blood typing and cross-matching antihistamine
2. Which of the following will probably result in a the sterile field c. Bleeding and clotting time d. Apply corn starch soaks to the rash
break in sterile technique for respiratory d. Pouring out a small amount of solution d. Complete blood count (CBC) and 21. All of the following nursing interventions are
isolation? (15 to 30 ml) before pouring the solution electrolyte levels. correct when using the Z-track method of drug
a. Opening the patient’s window to the into a sterile container 15. The primary purpose of a platelet count is to injection except:
outside environment 9. A natural body defense that plays an active role evaluate the: a. Prepare the injection site with alcohol
b. Turning on the patient’s room ventilator in preventing infection is: a. Potential for clot formation b. Use a needle that’s a least 1” long
c. Opening the door of the patient’s room a. Yawning b. Potential for bleeding c. Aspirate for blood before injection
leading into the hospital corridor b. Body hair c. Presence of an antigen-antibody d. Rub the site vigorously after the
d. Failing to wear gloves when c. Hiccupping response injection to promote absorption
administering a bed bath d. Rapid eye movements d. Presence of cardiac enzymes 22. The correct method for determining the vastus
3. Which of the following patients is at greater risk 10. All of the following statement are true about 16. Which of the following white blood cell (WBC) lateralis site for I.M. injection is to:
for contracting an infection? donning sterile gloves except: counts clearly indicates leukocytosis? a. Locate the upper aspect of the upper
a. A patient with leukopenia a. The first glove should be picked up by a. 4,500/mm³ outer quadrant of the buttock about 5 to
b. A patient receiving broad-spectrum grasping the inside of the cuff. b. 7,000/mm³ 8 cm below the iliac crest
antibiotics b. The second glove should be picked up by c. 10,000/mm³ b. Palpate the lower edge of the acromion
c. A postoperative patient who has inserting the gloved fingers under the d. 25,000/mm³ process and the midpoint lateral aspect
undergone orthopedic surgery cuff outside the glove. 17. After 5 days of diuretic therapy with 20mg of of the arm
d. A newly diagnosed diabetic patient c. The gloves should be adjusted by sliding furosemide (Lasix) daily, a patient begins to c. Palpate a 1” circular area anterior to the
4. Effective hand washing requires the use of: the gloved fingers under the sterile cuff exhibit fatigue, muscle cramping and muscle umbilicus
a. Soap or detergent to promote and pulling the glove over the wrist weakness. These symptoms probably indicate d. Divide the area between the greater
emulsification d. The inside of the glove is considered that the patient is experiencing: femoral trochanter and the lateral
b. Hot water to destroy bacteria sterile a. Hypokalemia femoral condyle into thirds, and select
c. A disinfectant to increase surface 11. When removing a contaminated gown, the nurse b. Hyperkalemia the middle third on the anterior of the
tension should be careful that the first thing she touches c. Anorexia thigh
d. All of the above is the: d. Dysphagia 23. The mid-deltoid injection site is seldom used for
5. After routine patient contact, hand washing a. Waist tie and neck tie at the back of the 18. Which of the following statements about chest I.M. injections because it:
should last at least: gown X-ray is false? a. Can accommodate only 1 ml or less of
a. 30 seconds b. Waist tie in front of the gown a. No contradictions exist for this test medication
b. 1 minute c. Cuffs of the gown b. Before the procedure, the patient should b. Bruises too easily
c. 2 minute d. Inside of the gown remove all jewelry, metallic objects, and c. Can be used only when the patient is
d. 3 minutes 12. Which of the following nursing interventions is buttons above the waist lying down
6. Which of the following procedures always considered the most effective form or universal c. A signed consent is not required d. Does not readily parenteral medication
requires surgical asepsis? precautions? d. Eating, drinking, and medications are 24. The appropriate needle size for insulin injection
a. Vaginal instillation of conjugated a. Cap all used needles before removing allowed before this test is:
estrogen them from their syringes 19. The most appropriate time for the nurse to a. 18G, 1 ½” long
b. Urinary catheterization b. Discard all used uncapped needles and obtain a sputum specimen for culture is: b. 22G, 1” long
c. Nasogastric tube insertion syringes in an impenetrable protective a. Early in the morning c. 22G, 1 ½” long
d. Colostomy irrigation container b. After the patient eats a light breakfast d. 25G, 5/8” long
7. Sterile technique is used whenever: c. Wear gloves when administering IM c. After aerosol therapy 25. The appropriate needle gauge for intradermal
a. Strict isolation is required injections d. After chest physiotherapy injection is:
b. Terminal disinfection is performed d. Follow enteric precautions 20. A patient with no known allergies is to receive a. 20G
c. Invasive procedures are performed 13. All of the following measures are recommended penicillin every 6 hours. When administering the b. 22G
d. Protective isolation is necessary to prevent pressure ulcers except: medication, the nurse observes a fine rash on c. 25G
a. Massaging the reddened are with lotion d. 26G
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26. Parenteral penicillin can be administered as an: b. Capsules whole contents are dissolve in b. Change the urine’s color b. Applying a topical antiseptic to the skin
a. IM injection or an IV solution water c. Change the urine’s concentration on the evening before surgery
b. IV or an intradermal injection c. Enteric-coated tablets that are d. Inhibit the growth of microorganisms c. Having the patient take a tub bath on
c. Intradermal or subcutaneous injection thoroughly dissolved in water 40. Clay colored stools indicate: the morning of surgery
d. IM or a subcutaneous injection d. Most tablets designed for oral use, a. Upper GI bleeding d. Having the patient shower with an
27. The physician orders gr 10 of aspirin for a except for extended-duration b. Impending constipation antiseptic soap on the evening v=before
patient. The equivalent dose in milligrams is: compounds c. An effect of medication and the morning of surgery
a. 0.6 mg 34. A patient who develops hives after receiving an d. Bile obstruction 47. When transferring a patient from a bed to a
b. 10 mg antibiotic is exhibiting drug: 41. In which step of the nursing process would the chair, the nurse should use which muscles to
c. 60 mg a. Tolerance nurse ask a patient if the medication she avoid back injury?
d. 600 mg b. Idiosyncrasy administered relieved his pain? a. Abdominal muscles
28. The physician orders an IV solution of dextrose c. Synergism a. Assessment b. Back muscles
5% in water at 100ml/hour. What would the d. Allergy b. Analysis c. Leg muscles
flow rate be if the drop factor is 15 gtt = 1 ml? 35. A patient has returned to his room after femoral c. Planning d. Upper arm muscles
a. 5 gtt/minute arteriography. All of the following are d. Evaluation 48. Thrombophlebitis typically develops in patients
b. 13 gtt/minute appropriate nursing interventions except: 42. All of the following are good sources of vitamin A with which of the following conditions?
c. 25 gtt/minute a. Assess femoral, popliteal, and pedal except: a. Increases partial thromboplastin time
d. 50 gtt/minute pulses every 15 minutes for 2 hours a. White potatoes b. Acute pulsus paradoxus
29. Which of the following is a sign or symptom of a b. Check the pressure dressing for b. Carrots c. An impaired or traumatized blood vessel
hemolytic reaction to blood transfusion? sanguineous drainage c. Apricots wall
a. Hemoglobinuria c. Assess a vital signs every 15 minutes for d. Egg yolks d. Chronic Obstructive Pulmonary Disease
b. Chest pain 2 hours 43. Which of the following is a primary nursing (COPD)
c. Urticaria d. Order a hemoglobin and hematocrit intervention necessary for all patients with a 49. In a recumbent, immobilized patient, lung
d. Distended neck veins count 1 hour after the arteriography Foley Catheter in place? ventilation can become altered, leading to such
30. Which of the following conditions may require 36. The nurse explains to a patient that a cough: a. Maintain the drainage tubing and respiratory complications as:
fluid restriction? a. Is a protective response to clear the collection bag level with the patient’s a. Respiratory acidosis, ateclectasis, and
a. Fever respiratory tract of irritants bladder hypostatic pneumonia
b. Chronic Obstructive Pulmonary Disease b. Is primarily a voluntary action b. Irrigate the patient with 1% Neosporin b. Appneustic breathing, atypical
c. Renal Failure c. Is induced by the administration of an solution three times a daily pneumonia and respiratory alkalosis
d. Dehydration antitussive drug c. Clamp the catheter for 1 hour every 4 c. Cheyne-Strokes respirations and
31. All of the following are common signs and d. Can be inhibited by “splinting” the hours to maintain the bladder’s elasticity spontaneous pneumothorax
symptoms of phlebitis except: abdomen d. Maintain the drainage tubing and d. Kussmail’s respirations and
a. Pain or discomfort at the IV insertion site 37. An infected patient has chills and begins collection bag below bladder level to hypoventilation
b. Edema and warmth at the IV insertion shivering. The best nursing intervention is to: facilitate drainage by gravity 50. Immobility impairs bladder elimination, resulting
site a. Apply iced alcohol sponges 44. The ELISA test is used to: in such disorders as
c. A red streak exiting the IV insertion site b. Provide increased cool liquids a. Screen blood donors for antibodies to a. Increased urine acidity and relaxation of
d. Frank bleeding at the insertion site c. Provide additional bedclothes human immunodeficiency virus (HIV) the perineal muscles, causing
32. The best way of determining whether a patient d. Provide increased ventilation b. Test blood to be used for transfusion for incontinence
has learned to instill ear medication properly is 38. A clinical nurse specialist is a nurse who has: HIV antibodies b. Urine retention, bladder distention, and
for the nurse to: a. Been certified by the National League for c. Aid in diagnosing a patient with AIDS infection
a. Ask the patient if he/she has used ear Nursing d. All of the above c. Diuresis, natriuresis, and decreased
drops before b. Received credentials from the Philippine 45. The two blood vessels most commonly used for urine specific gravity
b. Have the patient repeat the nurse’s Nurses’ Association TPN infusion are the: d. Decreased calcium and phosphate levels
instructions using her own words c. Graduated from an associate degree a. Subclavian and jugular veins in the urine
c. Demonstrate the procedure to the program and is a registered professional b. Brachial and subclavian veins
patient and encourage to ask questions nurse c. Femoral and subclavian veins
d. Ask the patient to demonstrate the d. Completed a master’s degree in the d. Brachial and femoral veins
procedure prescribed clinical area and is a 46. Effective skin disinfection before a surgical
33. Which of the following types of medications can registered professional nurse. procedure includes which of the following
be administered via gastrostomy tube? 39. The purpose of increasing urine acidity through methods?
a. Any oral medications dietary means is to: a. Shaving the site on the day before
a. Decrease burning sensations surgery
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ANSWERS and RATIONALES for FUNDAMENTALS OF equipment after a patient has been discharged incompatible, hemolysis and antigen-antibody corn starch to the rash may relieve discomfort, it
NURSING PART 3 to prepare them for reuse by another patient. reactions will occur. is not the nurse’s top priority in such a
The purpose of protective (reverse) isolation is 15. A. Platelets are disk-shaped cells that are potentially life-threatening situation.
1. D. In the circular chain of infection, pathogens to prevent a person with seriously impaired essential for blood coagulation. A platelet count 21. D. The Z-track method is an I.M. injection
must be able to leave their reservoir and be resistance from coming into contact who determines the number of thrombocytes in technique in which the patient’s skin is pulled in
transmitted to a susceptible host through a potentially pathogenic organisms. blood available for promoting hemostasis and such a way that the needle track is sealed off
portal of entry, such as broken skin. 8. C. The edges of a sterile field are considered assisting with blood coagulation after injury. It after the injection. This procedure seals
2. C. Respiratory isolation, like strict isolation, contaminated. When sterile items are allowed to also is used to evaluate the patient’s potential medication deep into the muscle, thereby
requires that the door to the door patient’s come in contact with the edges of the field, the for bleeding; however, this is not its primary minimizing skin staining and irritation. Rubbing
room remain closed. However, the patient’s sterile items also become contaminated. purpose. The normal count ranges from 150,000 the injection site is contraindicated because it
room should be well ventilated, so opening the 9. B. Hair on or within body areas, such as the to 350,000/mm3. A count of 100,000/mm3 or may cause the medication to extravasate into
window or turning on the ventricular is nose, traps and holds particles that contain less indicates a potential for bleeding; count of the skin.
desirable. The nurse does not need to wear microorganisms. Yawning and hiccupping do not less than 20,000/mm3 is associated with 22. D. The vastus lateralis, a long, thick muscle that
gloves for respiratory isolation, but good hand prevent microorganisms from entering or spontaneous bleeding. extends the full length of the thigh, is viewed by
washing is important for all types of isolation. leaving the body. Rapid eye movement marks 16. D. Leukocytosis is any transient increase in the many clinicians as the site of choice for I.M.
3. A. Leukopenia is a decreased number of the stage of sleep during which dreaming occurs. number of white blood cells (leukocytes) in the injections because it has relatively few major
leukocytes (white blood cells), which are 10. D. The inside of the glove is always considered to blood. Normal WBC counts range from 5,000 to nerves and blood vessels. The middle third of the
important in resisting infection. None of the be clean, but not sterile. 100,000/mm3. Thus, a count of 25,000/mm3 muscle is recommended as the injection site.
other situations would put the patient at risk for 11. A. The back of the gown is considered clean, the indicates leukocytosis. The patient can be in a supine or sitting position
contracting an infection; taking broad-spectrum front is contaminated. So, after removing gloves 17. A. Fatigue, muscle cramping, and muscle for an injection into this site.
antibiotics might actually reduce the infection and washing hands, the nurse should untie the weaknesses are symptoms of hypokalemia (an 23. A. The mid-deltoid injection site can
risk. back of the gown; slowly move backward away inadequate potassium level), which is a potential accommodate only 1 ml or less of medication
4. A. Soaps and detergents are used to help from the gown, holding the inside of the gown side effect of diuretic therapy. The physician because of its size and location (on the deltoid
remove bacteria because of their ability to lower and keeping the edges off the floor; turn and usually orders supplemental potassium to muscle of the arm, close to the brachial artery
the surface tension of water and act as fold the gown inside out; discard it in a prevent hypokalemia in patients receiving and radial nerve).
emulsifying agents. Hot water may lead to skin contaminated linen container; then wash her diuretics. Anorexia is another symptom of 24. D. A 25G, 5/8” needle is the recommended size
irritation or burns. hands again. hypokalemia. Dysphagia means difficulty for insulin injection because insulin is
5. A. Depending on the degree of exposure to 12. B. According to the Centers for Disease Control swallowing. administered by the subcutaneous route. An
pathogens, hand washing may last from 10 (CDC), blood-to-blood contact occurs most 18. A. Pregnancy or suspected pregnancy is the only 18G, 1 ½” needle is usually used for I.M.
seconds to 4 minutes. After routine patient commonly when a health care worker attempts contraindication for a chest X-ray. However, if a injections in children, typically in the vastus
contact, hand washing for 30 seconds effectively to cap a used needle. Therefore, used needles chest X-ray is necessary, the patient can wear a lateralis. A 22G, 1 ½” needle is usually used for
minimizes the risk of pathogen transmission. should never be recapped; instead they should lead apron to protect the pelvic region from adult I.M. injections, which are typically
6. B. The urinary system is normally free of be inserted in a specially designed puncture radiation. Jewelry, metallic objects, and buttons administered in the vastus lateralis or
microorganisms except at the urinary meatus. resistant, labeled container. Wearing gloves is would interfere with the X-ray and thus should ventrogluteal site.
Any procedure that involves entering this system not always necessary when administering an I.M. not be worn above the waist. A signed consent is 25. D. Because an intradermal injection does not
must use surgically aseptic measures to maintain injection. Enteric precautions prevent the not required because a chest X-ray is not an penetrate deeply into the skin, a small-bore 25G
a bacteria-free state. transfer of pathogens via feces. invasive examination. Eating, drinking and needle is recommended. This type of injection is
7. C. All invasive procedures, including surgery, 13. A. Nurses and other health care professionals medications are allowed because the X-ray is of used primarily to administer antigens to
catheter insertion, and administration of previously believed that massaging a reddened the chest, not the abdominal region. evaluate reactions for allergy or sensitivity
parenteral therapy, require sterile technique to area with lotion would promote venous return 19. A. Obtaining a sputum specimen early in this studies. A 20G needle is usually used for I.M.
maintain a sterile environment. All equipment and reduce edema to the area. However, morning ensures an adequate supply of bacteria injections of oil-based medications; a 22G needle
must be sterile, and the nurse and the physician research has shown that massage only increases for culturing and decreases the risk of for I.M. injections; and a 25G needle, for I.M.
must wear sterile gloves and maintain surgical the likelihood of cellular ischemia and necrosis contamination from food or medication. injections; and a 25G needle, for subcutaneous
asepsis. In the operating room, the nurse and to the area. 20. A. Initial sensitivity to penicillin is commonly insulin injections.
physician are required to wear sterile gowns, 14. B. Before a blood transfusion is performed, the manifested by a skin rash, even in individuals 26. A. Parenteral penicillin can be administered I.M.
gloves, masks, hair covers, and shoe covers for blood of the donor and recipient must be who have not been allergic to it previously. or added to a solution and given I.V. It cannot be
all invasive procedures. Strict isolation requires checked for compatibility. This is done by blood Because of the danger of anaphylactic shock, he administered subcutaneously or intradermally.
the use of clean gloves, masks, gowns and typing (a test that determines a person’s blood nurse should withhold the drug and notify the 27. D. gr 10 x 60mg/gr 1 = 600 mg
equipment to prevent the transmission of highly type) and cross-matching (a procedure that physician, who may choose to substitute 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
communicable diseases by contact or by determines the compatibility of the donor’s and another drug. Administering an antihistamine is 29. A. Hemoglobinuria, the abnormal presence of
airborne routes. Terminal disinfection is the recipient’s blood after the blood types has been a dependent nursing intervention that requires a hemoglobin in the urine, indicates a hemolytic
disinfection of all contaminated supplies and matched). If the blood specimens are written physician’s order. Although applying reaction (incompatibility of the donor’s and
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recipient’s blood). In this reaction, antibodies in 35. D. A hemoglobin and hematocrit count would be discolor stool – for example, drugs containing blood vessel wall. Increased partial
the recipient’s plasma combine rapidly with ordered by the physician if bleeding were iron turn stool black.; beets turn stool red. thromboplastin time indicates a prolonged
donor RBC’s; the cells are hemolyzed in either suspected. The other answers are appropriate 41. D. In the evaluation step of the nursing process, bleeding time during fibrin clot formation,
circulatory or reticuloendothelial system. nursing interventions for a patient who has the nurse must decide whether the patient has commonly the result of anticoagulant (heparin)
Hemolysis occurs more rapidly in ABO undergone femoral arteriography. achieved the expected outcome that was therapy. Arterial blood disorders (such as pulsus
incompatibilities than in Rh incompatibilities. 36. A. Coughing, a protective response that clears identified in the planning phase. paradoxus) and lung diseases (such as COPD) do
Chest pain and urticaria may be symptoms of the respiratory tract of irritants, usually is 42. A. The main sources of vitamin A are yellow and not necessarily impede venous return of injure
impending anaphylaxis. Distended neck veins are involuntary; however it can be voluntary, as green vegetables (such as carrots, sweet vessel walls.
an indication of hypervolemia. when a patient is taught to perform coughing potatoes, squash, spinach, collard greens, 49. A. Because of restricted respiratory movement,
30. C. In real failure, the kidney loses their ability to exercises. An antitussive drug inhibits coughing. broccoli, and cabbage) and yellow fruits (such as a recumbent, immobilize patient is at particular
effectively eliminate wastes and fluids. Because Splinting the abdomen supports the abdominal apricots, and cantaloupe). Animal sources risk for respiratory acidosis from poor gas
of this, limiting the patient’s intake of oral and muscles when a patient coughs. include liver, kidneys, cream, butter, and egg exchange; atelectasis from reduced surfactant
I.V. fluids may be necessary. Fever, chronic 37. C. In an infected patient, shivering results from yolks. and accumulated mucus in the bronchioles, and
obstructive pulmonary disease, and dehydration the body’s attempt to increase heat production 43. D. Maintaing the drainage tubing and collection hypostatic pneumonia from bacterial growth
are conditions for which fluids should be and the production of neutrophils and bag level with the patient’s bladder could result caused by stasis of mucus secretions.
encouraged. phagocytotic action through increased skeletal in reflux of urine into the kidney. Irrigating the 50. B. The immobilized patient commonly suffers
31. D. Phlebitis, the inflammation of a vein, can be muscle tension and contractions. Initial bladder with Neosporin and clamping the from urine retention caused by decreased
caused by chemical irritants (I.V. solutions or vasoconstriction may cause skin to feel cold to catheter for 1 hour every 4 hours must be muscle tone in the perineum. This leads to
medications), mechanical irritants (the needle or the touch. Applying additional bed clothes helps prescribed by a physician. bladder distention and urine stagnation, which
catheter used during venipuncture or to equalize the body temperature and stop the 44. D. The ELISA test of venous blood is used to provide an excellent medium for bacterial
cannulation), or a localized allergic reaction to chills. Attempts to cool the body result in further assess blood and potential blood donors to growth leading to infection. Immobility also
the needle or catheter. Signs and symptoms of shivering, increased metabloism, and thus human immunodeficiency virus (HIV). A positive results in more alkaline urine with excessive
phlebitis include pain or discomfort, edema and increased heat production. ELISA test combined with various signs and amounts of calcium, sodium and phosphate, a
heat at the I.V. insertion site, and a red streak 38. D. A clinical nurse specialist must have symptoms helps to diagnose acquired gradual decrease in urine production, and an
going up the arm or leg from the I.V. insertion completed a master’s degree in a clinical immunodeficiency syndrome (AIDS) increased specific gravity
site. specialty and be a registered professional nurse. 45. D. Tachypnea (an abnormally rapid rate of
32. D. Return demonstration provides the most The National League of Nursing accredits breathing) would indicate that the patient was
certain evidence for evaluating the effectiveness educational programs in nursing and provides a still hypoxic (deficient in oxygen).The partial
of patient teaching. testing service to evaluate student nursing pressures of arterial oxygen and carbon dioxide
33. D. Capsules, enteric-coated tablets, and most competence but it does not certify nurses. The listed are within the normal range. Eupnea refers
extended duration or sustained release products American Nurses Association identifies to normal respiration.
should not be dissolved for use in a gastrostomy requirements for certification and offers 46. D. Studies have shown that showering with an
tube. They are pharmaceutically manufactured examinations for certification in many areas of antiseptic soap before surgery is the most
in these forms for valid reasons, and altering nursing., such as medical surgical nursing. These effective method of removing microorganisms
them destroys their purpose. The nurse should certification (credentialing) demonstrates that from the skin. Shaving the site of the intended
seek an alternate physician’s order when an the nurse has the knowledge and the ability to surgery might cause breaks in the skin, thereby
ordered medication is inappropriate for delivery provide high quality nursing care in the area of increasing the risk of infection; however, if
by tube. her certification. A graduate of an associate indicated, shaving, should be done immediately
34. D. A drug-allergy is an adverse reaction resulting degree program is not a clinical nurse specialist: before surgery, not the day before. A topical
from an immunologic response following a however, she is prepared to provide bed side antiseptic would not remove microorganisms
previous sensitizing exposure to the drug. The nursing with a high degree of knowledge and and would be beneficial only after proper
reaction can range from a rash or hives to skill. She must successfully complete the cleaning and rinsing. Tub bathing might transfer
anaphylactic shock. Tolerance to a drug means licensing examination to become a registered organisms to another body site rather than rinse
that the patient experiences a decreasing professional nurse. them away.
physiologic response to repeated administration 39. D. Microorganisms usually do not grow in an 47. C. The leg muscles are the strongest muscles in
of the drug in the same dosage. Idiosyncrasy is acidic environment. the body and should bear the greatest stress
an individual’s unique hypersensitivity to a drug, 40. D. Bile colors the stool brown. Any inflammation when lifting. Muscles of the abdomen, back, and
food, or other substance; it appears to be or obstruction that impairs bile flow will affect upper arms may be easily injured.
genetically determined. Synergism, is a drug the stool pigment, yielding light, clay-colored 48. C. The factors, known as Virchow’s triad,
interaction in which the sum of the drug’s stool. Upper GI bleeding results in black or tarry collectively predispose a patient to
combined effects is greater than that of their stool. Constipation is characterized by small, thromboplebitis; impaired venous return to the
separate effects. hard masses. Many medications and foods will heart, blood hypercoagulability, and injury to a
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MATERNITY NURSING Part 1 7. Which of the following represents the average d. There is a greater chance for error 21. During which of the following stages of labor
amount of weight gained during pregnancy? during preparation would the nurse assess “crowning”?
1. When assessing the adequacy of sperm for a. 12 to 22 lb 14. Which of the following would cause a false- a. First stage
conception to occur, which of the following is b. 15 to 25 lb positive result on a pregnancy test? b. Second stage
the most useful criterion? c. 24 to 30 lb a. The test was performed less than 10 c. Third stage
a. Sperm count d. 25 to 40 lb days after an abortion d. Fourth stage
b. Sperm motility 8. When talking with a pregnant client who is b. The test was performed too early or too 22. Barbiturates are usually not given for pain relief
c. Sperm maturity experiencing aching swollen, leg veins, the nurse late in the pregnancy during active labor for which of the following
d. Semen volume would explain that this is most probably the c. The urine sample was stored too long at reasons?
2. A couple who wants to conceive but has been result of which of the following? room temperature a. The neonatal effects include hypotonia,
unsuccessful during the last 2 years has a. Thrombophlebitis d. A spontaneous abortion or a missed hypothermia, generalized drowsiness,
undergone many diagnostic procedures. When b. Pregnancy-induced hypertension abortion is impending and reluctance to feed for the first few
discussing the situation with the nurse, one c. Pressure on blood vessels from the 15. FHR can be auscultated with a fetoscope as early days.
partner states, “We know several friends in our enlarging uterus as which of the following? b. These drugs readily cross the placental
age group and all of them have their own child d. The force of gravity pulling down on the a. 5 weeks gestation barrier, causing depressive effects in the
already, Why can’t we have one?”. Which of the uterus b. 10 weeks gestation newborn 2 to 3 hours after
following would be the most pertinent nursing 9. Cervical softening and uterine souffle are c. 15 weeks gestation intramuscular injection.
diagnosis for this couple? classified as which of the following? d. 20 weeks gestation c. They rapidly transfer across the
a. Fear related to the unknown a. Diagnostic signs 16. A client LMP began July 5. Her EDD should be placenta, and lack of an antagonist make
b. Pain related to numerous procedures. b. Presumptive signs which of the following? them generally inappropriate during
c. Ineffective family coping related to c. Probable signs a. January 2 labor.
infertility. d. Positive signs b. March 28 d. Adverse reactions may include maternal
d. Self-esteem disturbance related to 10. Which of the following would the nurse identify c. April 12 hypotension, allergic or toxic reaction or
infertility. as a presumptive sign of pregnancy? d. October 12 partial or total respiratory failure
3. Which of the following urinary symptoms does a. Hegar sign 17. Which of the following fundal heights indicates 23. Which of the following nursing interventions
the pregnant woman most frequently b. Nausea and vomiting less than 12 weeks’ gestation when the date of would the nurse perform during the third stage
experience during the first trimester? c. Skin pigmentation changes the LMP is unknown? of labor?
a. Dysuria d. Positive serum pregnancy test a. Uterus in the pelvis a. Obtain a urine specimen and other
b. Frequency 11. Which of the following common emotional b. Uterus at the xiphoid laboratory tests.
c. Incontinence reactions to pregnancy would the nurse expect c. Uterus in the abdomen b. Assess uterine contractions every 30
d. Burning to occur during the first trimester? d. Uterus at the umbilicus minutes.
4. Heartburn and flatulence, common in the a. Introversion, egocentrism, narcissism 18. Which of the following danger signs should be c. Coach for effective client pushing
second trimester, are most likely the result of b. Awkwardness, clumsiness, and reported promptly during the antepartum d. Promote parent-newborn interaction.
which of the following? unattractiveness period? 24. Which of the following actions demonstrates the
a. Increased plasma HCG levels c. Anxiety, passivity, extroversion a. Constipation nurse’s understanding about the newborn’s
b. Decreased intestinal motility d. Ambivalence, fear, fantasies b. Breast tenderness thermoregulatory ability?
c. Decreased gastric acidity 12. During which of the following would the focus of c. Nasal stuffiness a. Placing the newborn under a radiant
d. Elevated estrogen levels classes be mainly on physiologic changes, fetal d. Leaking amniotic fluid warmer.
5. On which of the following areas would the nurse development, sexuality, during pregnancy, and 19. Which of the following prenatal laboratory test b. Suctioning with a bulb syringe
expect to observe chloasma? nutrition? values would the nurse consider as significant? c. Obtaining an Apgar score
a. Breast, areola, and nipples a. Prepregnant period a. Hematocrit 33.5% d. Inspecting the newborn’s umbilical cord
b. Chest, neck, arms, and legs b. First trimester b. Rubella titer less than 1:8 25. Immediately before expulsion, which of the
c. Abdomen, breast, and thighs c. Second trimester c. White blood cells 8,000/mm3 following cardinal movements occur?
d. Cheeks, forehead, and nose d. Third trimester d. One hour glucose challenge test 110 a. Descent
6. A pregnant client states that she “waddles” 13. Which of the following would be disadvantage of g/dL b. Flexion
when she walks. The nurse’s explanation is breast feeding? 20. Which of the following characteristics of c. Extension
based on which of the following as the cause? a. Involution occurs more rapidly contractions would the nurse expect to find in a d. External rotation
a. The large size of the newborn b. The incidence of allergies increases due client experiencing true labor? 26. Before birth, which of the following structures
b. Pressure on the pelvic muscles to maternal antibodies a. Occurring at irregular intervals connects the right and left auricles of the heart?
c. Relaxation of the pelvic joints c. The father may resent the infant’s b. Starting mainly in the abdomen a. Umbilical vein
d. Excessive weight gain demands on the mother’s body c. Gradually increasing intervals b. Foramen ovale
d. Increasing intensity with walking c. Ductus arteriosus
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d. Ductus venosus 32. Which of the following statements best 38. Which of the following may happen if the uterus 43. When uterine rupture occurs, which of the
27. Which of the following when present in the describes hyperemesis gravidarum? becomes overstimulated by oxytocin during the following would be the priority?
urine may cause a reddish stain on the diaper of a. Severe anemia leading to electrolyte, induction of labor? a. Limiting hypovolemic shock
a newborn? metabolic, and nutritional imbalances in a. Weak contraction prolonged to more b. Obtaining blood specimens
a. Mucus the absence of other medical problems. than 70 seconds c. Instituting complete bed rest
b. Uric acid crystals b. Severe nausea and vomiting leading to b. Tetanic contractions prolonged to more d. Inserting a urinary catheter
c. Bilirubin electrolyte, metabolic, and nutritional than 90 seconds 44. Which of the following is the nurse’s initial
d. Excess iron imbalances in the absence of other c. Increased pain with bright red vaginal action when umbilical cord prolapse occurs?
28. When assessing the newborn’s heart rate, which medical problems. bleeding a. Begin monitoring maternal vital signs
of the following ranges would be considered c. Loss of appetite and continuous d. Increased restlessness and anxiety and FHR
normal if the newborn were sleeping? vomiting that commonly results in 39. When preparing a client for cesarean delivery, b. Place the client in a knee-chest position
a. 80 beats per minute dehydration and ultimately decreasing which of the following key concepts should be in bed
b. 100 beats per minute maternal nutrients considered when implementing nursing care? c. Notify the physician and prepare the
c. 120 beats per minute d. Severe nausea and diarrhea that can a. Instruct the mother’s support person to client for delivery
d. 140 beats per minute cause gastrointestinal irritation and remain in the family lounge until after d. Apply a sterile warm saline dressing to
29. Which of the following is true regarding the possibly internal bleeding the delivery the exposed cord
fontanels of the newborn? 33. Which of the following would the nurse identify b. Arrange for a staff member of the 45. Which of the following amounts of blood loss
a. The anterior is triangular shaped; the as a classic sign of PIH? anesthesia department to explain what following birth marks the criterion for describing
posterior is diamond shaped. a. Edema of the feet and ankles to expect postoperatively postpartum hemorrhage?
b. The posterior closes at 18 months; the b. Edema of the hands and face c. Modify preoperative teaching to meet a. More than 200 ml
anterior closes at 8 to 12 weeks. c. Weight gain of 1 lb/week the needs of either a planned or b. More than 300 ml
c. The anterior is large in size when d. Early morning headache emergency cesarean birth c. More than 400 ml
compared to the posterior fontanel. 34. In which of the following types of spontaneous d. Explain the surgery, expected outcome, d. More than 500 ml
d. The anterior is bulging; the posterior abortions would the nurse assess dark brown and kind of anesthetics 46. Which of the following is the primary
appears sunken. vaginal discharge and a negative pregnancy 40. Which of the following best describes preterm predisposing factor related to mastitis?
30. Which of the following groups of newborn tests? labor? a. Epidemic infection from nosocomial
reflexes below are present at birth and remain a. Threatened a. Labor that begins after 20 weeks sources localizing in the lactiferous
unchanged through adulthood? b. Imminent gestation and before 37 weeks gestation glands and ducts
a. Blink, cough, rooting, and gag c. Missed b. Labor that begins after 15 weeks b. Endemic infection occurring randomly
b. Blink, cough, sneeze, gag d. Incomplete gestation and before 37 weeks gestation and localizing in the periglandular
c. Rooting, sneeze, swallowing, and cough 35. Which of the following factors would the nurse c. Labor that begins after 24 weeks connective tissue
d. Stepping, blink, cough, and sneeze suspect as predisposing a client to placenta gestation and before 28 weeks gestation c. Temporary urinary retention due to
31. Which of the following describes the Babinski previa? d. Labor that begins after 28 weeks decreased perception of the urge to
reflex? a. Multiple gestation gestation and before 40 weeks gestation avoid
a. The newborn’s toes will hyperextend b. Uterine anomalies 41. When PROM occurs, which of the following d. Breast injury caused by overdistention,
and fan apart from dorsiflexion of the c. Abdominal trauma provides evidence of the nurse’s understanding stasis, and cracking of the nipples
big toe when one side of foot is stroked d. Renal or vascular disease of the client’s immediate needs? 47. Which of the following best describes
upward from the ball of the heel and 36. Which of the following would the nurse assess in a. The chorion and amnion rupture 4 hours thrombophlebitis?
across the ball of the foot. a client experiencing abruptio placenta? before the onset of labor. a. Inflammation and clot formation that
b. The newborn abducts and flexes all a. Bright red, painless vaginal bleeding b. PROM removes the fetus most effective result when blood components combine
extremities and may begin to cry when b. Concealed or external dark red bleeding defense against infection to form an aggregate body
exposed to sudden movement or loud c. Palpable fetal outline c. Nursing care is based on fetal viability b. Inflammation and blood clots that
noise. d. Soft and nontender abdomen and gestational age. eventually become lodged within the
c. The newborn turns the head in the 37. Which of the following is described as premature d. PROM is associated with pulmonary blood vessels
direction of stimulus, opens the mouth, separation of a normally implanted placenta malpresentation and possibly c. Inflammation and blood clots that
and begins to suck when cheek, lip, or during the second half of pregnancy, usually with incompetent cervix eventually become lodged within the
corner of mouth is touched. severe hemorrhage? 42. Which of the following factors is the underlying femoral vein
d. The newborn will attempt to crawl a. Placenta previa cause of dystocia? d. Inflammation of the vascular
forward with both arms and legs when b. Ectopic pregnancy a. Nurtional endothelium with clot formation on the
he is placed on his abdomen on a flat c. Incompetent cervix b. Mechanical vessel wall
surface d. Abruptio placentae c. Environmental
d. Medical
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48. Which of the following assessment findings 53. When preparing a woman who is 2 days a. Stethoscope placed midline at the b. Administer a narcotic before breast
would the nurse expect if the client develops postpartum for discharge, recommendations for umbilicus feeding
DVT? which of the following contraceptive methods b. Doppler placed midline at the c. Encourage her to wear a nursing
a. Midcalf pain, tenderness and redness would be avoided? suprapubic region brassiere
along the vein a. Diaphragm c. Fetoscope placed midway between the d. Use soap and water to clean the nipples
b. Chills, fever, malaise, occurring 2 weeks b. Female condom umbilicus and the xiphoid process 66. The nurse assesses the vital signs of a client, 4
after delivery c. Oral contraceptives d. External electronic fetal monitor placed hours’ postpartum that are as follows: BP 90/60;
c. Muscle pain the presence of Homans d. Rhythm method at the umbilicus temperature 100.4ºF; pulse 100 weak, thready;
sign, and swelling in the affected limb 54. For which of the following clients would the 60. When developing a plan of care for a client R 20 per minute. Which of the following should
d. Chills, fever, stiffness, and pain occurring nurse expect that an intrauterine device would newly diagnosed with gestational diabetes, the nurse do first?
10 to 14 days after delivery not be recommended? which of the following instructions would be the a. Report the temperature to the physician
49. Which of the following are the most commonly a. Woman over age 35 priority? b. Recheck the blood pressure with
assessed findings in cystitis? b. Nulliparous woman a. Dietary intake another cuff
a. Frequency, urgency, dehydration, c. Promiscuous young adult b. Medication c. Assess the uterus for firmness and
nausea, chills, and flank pain d. Postpartum client c. Exercise position
b. Nocturia, frequency, urgency dysuria, 55. A client in her third trimester tells the nurse, d. Glucose monitoring d. Determine the amount of lochia
hematuria, fever and suprapubic pain “I’m constipated all the time!” Which of the 61. A client at 24 weeks gestation has gained 6 67. The nurse assesses the postpartum vaginal
c. Dehydration, hypertension, dysuria, following should the nurse recommend? pounds in 4 weeks. Which of the following would discharge (lochia) on four clients. Which of the
suprapubic pain, chills, and fever a. Daily enemas be the priority when assessing the client? following assessments would warrant
d. High fever, chills, flank pain nausea, b. Laxatives a. Glucosuria notification of the physician?
vomiting, dysuria, and frequency c. Increased fiber intake b. Depression a. A dark red discharge on a 2-day
50. Which of the following best reflects the d. Decreased fluid intake c. Hand/face edema postpartum client
frequency of reported postpartum “blues”? 56. Which of the following would the nurse use as d. Dietary intake b. A pink to brownish discharge on a client
a. Between 10% and 40% of all new the basis for the teaching plan when caring for a 62. A client 12 weeks’ pregnant come to the who is 5 days postpartum
mothers report some form of pregnant teenager concerned about gaining too emergency department with abdominal c. Almost colorless to creamy discharge on
postpartum blues much weight during pregnancy? cramping and moderate vaginal bleeding. a client 2 weeks after delivery
b. Between 30% and 50% of all new a. 10 pounds per trimester Speculum examination reveals 2 to 3 cms d. A bright red discharge 5 days after
mothers report some form of b. 1 pound per week for 40 weeks cervical dilation. The nurse would document delivery
postpartum blues c. ½ pound per week for 40 weeks these findings as which of the following? 68. A postpartum client has a temperature of
c. Between 50% and 80% of all new d. A total gain of 25 to 30 pounds a. Threatened abortion 101.4ºF, with a uterus that is tender when
mothers report some form of 57. The client tells the nurse that her last menstrual b. Imminent abortion palpated, remains unusually large, and not
postpartum blues period started on January 14 and ended on c. Complete abortion descending as normally expected. Which of the
d. Between 25% and 70% of all new January 20. Using Nagele’s rule, the nurse d. Missed abortion following should the nurse assess next?
mothers report some form of determines her EDD to be which of the 63. Which of the following would be the priority a. Lochia
postpartum blues following? nursing diagnosis for a client with an ectopic b. Breasts
51. For the client who is using oral contraceptives, a. September 27 pregnancy? c. Incision
the nurse informs the client about the need to b. October 21 a. Risk for infection d. Urine
take the pill at the same time each day to c. November 7 b. Pain 69. Which of the following is the priority focus of
accomplish which of the following? d. December 27 c. Knowledge Deficit nursing practice with the current early
a. Decrease the incidence of nausea 58. When taking an obstetrical history on a pregnant d. Anticipatory Grieving postpartum discharge?
b. Maintain hormonal levels client who states, “I had a son born at 38 weeks 64. Before assessing the postpartum client’s uterus a. Promoting comfort and restoration of
c. Reduce side effects gestation, a daughter born at 30 weeks gestation for firmness and position in relation to the health
d. Prevent drug interactions and I lost a baby at about 8 weeks,” the nurse umbilicus and midline, which of the following b. Exploring the emotional status of the
52. When teaching a client about contraception. should record her obstetrical history as which of should the nurse do first? family
Which of the following would the nurse include the following? a. Assess the vital signs c. Facilitating safe and effective self-and
as the most effective method for preventing a. G2 T2 P0 A0 L2 b. Administer analgesia newborn care
sexually transmitted infections? b. G3 T1 P1 A0 L2 c. Ambulate her in the hall d. Teaching about the importance of family
a. Spermicides c. G3 T2 P0 A0 L2 d. Assist her to urinate planning
b. Diaphragm d. G4 T2 P1 A1 L2 65. Which of the following should the nurse do 70. Which of the following actions would be least
c. Condoms 59. When preparing to listen to the fetal heart rate when a primipara who is lactating tells the nurse effective in maintaining a neutral thermal
d. Vasectomy at 12 weeks’ gestation, the nurse would use that she has sore nipples? environment for the newborn?
which of the following? a. Tell her to breast feed more frequently
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a. Placing infant under radiant warmer a. “Daily soap and water cleansing is best” which of the following sites as appropriate for 87. During a prenatal class, the nurse explains the
after bathing b. ‘Alcohol helps it dry and kills germs” the injection? rationale for breathing techniques during
b. Covering the scale with a warmed c. “An antibiotic ointment applied daily a. Deltoid muscle preparation for labor based on the
blanket prior to weighing prevents infection” b. Anterior femoris muscle understanding that breathing techniques are
c. Placing crib close to nursery window for d. “He can have a tub bath each day” c. Vastus lateralis muscle most important in achieving which of the
family viewing 76. A newborn weighing 3000 grams and feeding d. Gluteus maximus muscle following?
d. Covering the infant’s head with a knit every 4 hours needs 120 calories/kg of body 82. When performing a pelvic examination, the a. Eliminate pain and give the expectant
stockinette weight every 24 hours for proper growth and nurse observes a red swollen area on the right parents something to do
71. A newborn who has an asymmetrical Moro development. How many ounces of 20 cal/oz side of the vaginal orifice. The nurse would b. Reduce the risk of fetal distress by
reflex response should be further assessed for formula should this newborn receive at each document this as enlargement of which of the increasing uteroplacental perfusion
which of the following? feeding to meet nutritional needs? following? c. Facilitate relaxation, possibly reducing
a. Talipes equinovarus a. 2 ounces a. Clitoris the perception of pain
b. Fractured clavicle b. 3 ounces b. Parotid gland d. Eliminate pain so that less analgesia and
c. Congenital hypothyroidism c. 4 ounces c. Skene’s gland anesthesia are needed
d. Increased intracranial pressure d. 6 ounces d. Bartholin’s gland 88. After 4 hours of active labor, the nurse notes
72. During the first 4 hours after a male 77. The postterm neonate with meconium-stained 83. To differentiate as a female, the hormonal that the contractions of a primigravida client are
circumcision, assessing for which of the amniotic fluid needs care designed to especially stimulation of the embryo that must occur not strong enough to dilate the cervix. Which of
following is the priority? monitor for which of the following? involves which of the following? the following would the nurse anticipate doing?
a. Infection a. Respiratory problems a. Increase in maternal estrogen secretion a. Obtaining an order to begin IV oxytocin
b. Hemorrhage b. Gastrointestinal problems b. Decrease in maternal androgen infusion
c. Discomfort c. Integumentary problems secretion b. Administering a light sedative to allow
d. Dehydration d. Elimination problems c. Secretion of androgen by the fetal gonad the patient to rest for several hour
73. The mother asks the nurse. “What’s wrong with 78. When measuring a client’s fundal height, which d. Secretion of estrogen by the fetal gonad c. Preparing for a cesarean section for
my son’s breasts? Why are they so enlarged?” of the following techniques denotes the correct 84. A client at 8 weeks’ gestation calls complaining failure to progress
Whish of the following would be the best method of measurement used by the nurse? of slight nausea in the morning hours. Which of d. Increasing the encouragement to the
response by the nurse? a. From the xiphoid process to the the following client interventions should the patient when pushing begins
a. “The breast tissue is inflamed from the umbilicus nurse question? 89. A multigravida at 38 weeks’ gestation is
trauma experienced with birth” b. From the symphysis pubis to the xiphoid a. Taking 1 teaspoon of bicarbonate of admitted with painless, bright red bleeding and
b. “A decrease in material hormones process soda in an 8-ounce glass of water mild contractions every 7 to 10 minutes. Which
present before birth causes c. From the symphysis pubis to the fundus b. Eating a few low-sodium crackers before of the following assessments should be avoided?
enlargement,” d. From the fundus to the umbilicus getting out of bed a. Maternal vital sign
c. “You should discuss this with your 79. A client with severe preeclampsia is admitted c. Avoiding the intake of liquids in the b. Fetal heart rate
doctor. It could be a malignancy” with of BP 160/110, proteinuria, and severe morning hours c. Contraction monitoring
d. “The tissue has hypertrophied while the pitting edema. Which of the following would be d. Eating six small meals a day instead of d. Cervical dilation
baby was in the uterus” most important to include in the client’s plan of thee large meals 90. Which of the following would be the nurse’s
74. Immediately after birth the nurse notes the care? 85. The nurse documents positive ballottement in most appropriate response to a client who asks
following on a male newborn: respirations 78; a. Daily weights the client’s prenatal record. The nurse why she must have a cesarean delivery if she has
apical hearth rate 160 BPM, nostril flaring; mild b. Seizure precautions understands that this indicates which of the a complete placenta previa?
intercostal retractions; and grunting at the end c. Right lateral positioning following? a. “You will have to ask your physician
of expiration. Which of the following should the d. Stress reduction a. Palpable contractions on the abdomen when he returns.”
nurse do? 80. A postpartum primipara asks the nurse, “When b. Passive movement of the unengaged b. “You need a cesarean to prevent
a. Call the assessment data to the can we have sexual intercourse again?” Which of fetus hemorrhage.”
physician’s attention the following would be the nurse’s best c. Fetal kicking felt by the client c. “The placenta is covering most of your
b. Start oxygen per nasal cannula at 2 response? d. Enlargement and softening of the uterus cervix.”
L/min. a. “Anytime you both want to.” 86. During a pelvic exam the nurse notes a purple- d. “The placenta is covering the opening of
c. Suction the infant’s mouth and nares b. “As soon as choose a contraceptive blue tinge of the cervix. The nurse documents the uterus and blocking your baby.”
d. Recognize this as normal first period of method.” this as which of the following? 91. The nurse understands that the fetal head is in
reactivity c. “When the discharge has stopped and a. Braxton-Hicks sign which of the following positions with a face
75. The nurse hears a mother telling a friend on the the incision is healed.” b. Chadwick’s sign presentation?
telephone about umbilical cord care. Which of d. “After your 6 weeks examination.” c. Goodell’s sign a. Completely flexed
the following statements by the mother 81. When preparing to administer the vitamin K d. McDonald’s sign b. Completely extended
indicates effective teaching? injection to a neonate, the nurse would select c. Partially extended
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d. Partially flexed accident as a teenager. The nurse is aware that ANSWERS and RATIONALES for MATERNITY A weight gain of 25 to 40 lb is considered
92. With a fetus in the left-anterior breech this could prevent a fetus from passing through NURSING Part 1 excessive.
presentation, the nurse would expect the fetal or around which structure during childbirth? 8. C. Pressure of the growing uterus on blood
heart rate would be most audible in which of the a. Symphysis pubis 1. B. Although all of the factors listed are vessels results in an increased risk for venous
following areas? b. Sacral promontory important, sperm motility is the most significant stasis in the lower extremities. Subsequently,
a. Above the maternal umbilicus and to the c. Ischial spines criterion when assessing male infertility. Sperm edema and varicose vein formation may occur.
right of midline d. Pubic arch count, sperm maturity, and semen volume are Thrombophlebitis is an inflammation of the veins
b. In the lower-left maternal abdominal 99. When teaching a group of adolescents about all significant, but they are not as significant due to thrombus formation. Pregnancy-induced
quadrant variations in the length of the menstrual cycle, sperm motility. hypertension is not associated with these
c. In the lower-right maternal abdominal the nurse understands that the underlying 2. D. Based on the partner’s statement, the couple symptoms. Gravity plays only a minor role with
quadrant mechanism is due to variations in which of the is verbalizing feelings of inadequacy and these symptoms.
d. Above the maternal umbilicus and to the following phases? negative feelings about themselves and their 9. C. Cervical softening (Goodell sign) and uterine
left of midline a. Menstrual phase capabilities. Thus, the nursing diagnosis of self- soufflé are two probable signs of pregnancy.
93. The amniotic fluid of a client has a greenish tint. b. Proliferative phase esteem disturbance is most appropriate. Fear, Probable signs are objective findings that
The nurse interprets this to be the result of c. Secretory phase pain, and ineffective family coping also may be strongly suggest pregnancy. Other probable
which of the following? d. Ischemic phase present but as secondary nursing diagnoses. signs include Hegar sign, which is softening of
a. Lanugo 100. When teaching a group of adolescents 3. B. Pressure and irritation of the bladder by the the lower uterine segment; Piskacek sign, which
b. Hydramnio about male hormone production, which of the growing uterus during the first trimester is is enlargement and softening of the uterus;
c. Meconium following would the nurse include as being responsible for causing urinary frequency. serum laboratory tests; changes in skin
d. Vernix produced by the Leydig cells? Dysuria, incontinence, and burning are pigmentation; and ultrasonic evidence of a
94. A patient is in labor and has just been told she a. Follicle-stimulating hormone symptoms associated with urinary tract gestational sac. Presumptive signs are subjective
has a breech presentation. The nurse should be b. Testosterone infections. signs and include amenorrhea; nausea and
particularly alert for which of the following? c. Leuteinizing hormone 4. C. During the second trimester, the reduction in vomiting; urinary frequency; breast tenderness
a. Quickening d. Gonadotropin releasing hormone gastric acidity in conjunction with pressure from and changes; excessive fatigue; uterine
b. Ophthalmia neonatorum the growing uterus and smooth muscle enlargement; and quickening.
c. Pica relaxation, can cause heartburn and flatulence. 10. B. Presumptive signs of pregnancy are subjective
d. Prolapsed umbilical cord HCG levels increase in the first, not the second, signs. Of the signs listed, only nausea and
95. When describing dizygotic twins to a couple, on trimester. Decrease intestinal motility would vomiting are presumptive signs. Hegar sign, skin
which of the following would the nurse base the most likely be the cause of constipation and pigmentation changes, and a positive serum
explanation? bloating. Estrogen levels decrease in the second pregnancy test are considered probably signs,
a. Two ova fertilized by separate sperm trimester. which are strongly suggestive of pregnancy.
b. Sharing of a common placenta 5. D. Chloasma, also called the mask of pregnancy, 11. D. During the first trimester, common emotional
c. Each ova with the same genotype is an irregular hyperpigmented area found on reactions include ambivalence, fear, fantasies, or
d. Sharing of a common chorion the face. It is not seen on the breasts, areola, anxiety. The second trimester is a period of well-
96. Which of the following refers to the single cell nipples, chest, neck, arms, legs, abdomen, or being accompanied by the increased need to
that reproduces itself after conception? thighs. learn about fetal growth and development.
a. Chromosome 6. C. During pregnancy, hormonal changes cause Common emotional reactions during this
b. Blastocyst relaxation of the pelvic joints, resulting in the trimester include narcissism, passivity, or
c. Zygote typical “waddling” gait. Changes in posture are introversion. At times the woman may seem
d. Trophoblast related to the growing fetus. Pressure on the egocentric and self-centered. During the third
97. In the late 1950s, consumers and health care surrounding muscles causing discomfort is due trimester, the woman typically feels awkward,
professionals began challenging the routine use to the growing uterus. Weight gain has no effect clumsy, and unattractive, often becoming more
of analgesics and anesthetics during childbirth. on gait. introverted or reflective of her own childhood.
Which of the following was an outgrowth of this 7. C. The average amount of weight gained during 12. B. First-trimester classes commonly focus on
concept? pregnancy is 24 to 30 lb. This weight gain such issues as early physiologic changes, fetal
a. Labor, delivery, recovery, postpartum consists of the following: fetus – 7.5 lb; placenta development, sexuality during pregnancy, and
(LDRP) and membrane – 1.5 lb; amniotic fluid – 2 lb; nutrition. Some early classes may include
b. Nurse-midwifery uterus – 2.5 lb; breasts – 3 lb; and increased pregnant couples. Second and third trimester
c. Clinical nurse specialist blood volume – 2 to 4 lb; extravascular fluid and classes may focus on preparation for birth,
d. Prepared childbirth fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, parenting, and newborn care.
98. A client has a midpelvic contracture from a whereas a weight gain of 15 to 25 lb is marginal. 13. C. With breast feeding, the father’s body is not
previous pelvic injury due to a motor vehicle capable of providing the milk for the newborn,
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which may interfere with feeding the newborn, 20. D. With true labor, contractions increase in Suctioning with a bulb syringe helps maintain a legs when he is placed on his abdomen on a flat
providing fewer chances for bonding, or he may intensity with walking. In addition, true labor patent airway. Obtaining an Apgar score surface.
be jealous of the infant’s demands on his wife’s contractions occur at regular intervals, usually measures the newborn’s immediate adjustment 32. B. The description of hyperemesis gravidarum
time and body. Breast feeding is advantageous starting in the back and sweeping around to the to extrauterine life. Inspecting the umbilical cord includes severe nausea and vomiting, leading to
because uterine involution occurs more rapidly, abdomen. The interval of true labor contractions aids in detecting cord anomalies. electrolyte, metabolic, and nutritional
thus minimizing blood loss. The presence of gradually shortens. 25. D. Immediately before expulsion or birth of the imbalances in the absence of other medical
maternal antibodies in breast milk helps 21. B. Crowing, which occurs when the newborn’s rest of the body, the cardinal movement of problems. Hyperemesis is not a form of anemia.
decrease the incidence of allergies in the head or presenting part appears at the vaginal external rotation occurs. Descent flexion, Loss of appetite may occur secondary to the
newborn. A greater chance for error is opening, occurs during the second stage of internal rotation, extension, and restitution (in nausea and vomiting of hyperemesis, which, if it
associated with bottle feeding. No preparation is labor. During the first stage of labor, cervical this order) occur before external rotation. continues, can deplete the nutrients transported
required for breast feeding. dilation and effacement occur. During the third 26. B. The foramen ovale is an opening between the to the fetus. Diarrhea does not occur with
14. A. A false-positive reaction can occur if the stage of labor, the newborn and placenta are right and left auricles (atria) that should close hyperemesis.
pregnancy test is performed less than 10 days delivered. The fourth stage of labor lasts from 1 shortly after birth so the newborn will not have a 33. B. Edema of the hands and face is a classic sign
after an abortion. Performing the tests too early to 4 hours after birth, during which time the murmur or mixed blood traveling through the of PIH. Many healthy pregnant woman
or too late in the pregnancy, storing the urine mother and newborn recover from the physical vascular system. The umbilical vein, ductus experience foot and ankle edema. A weight gain
sample too long at room temperature, or having process of birth and the mother’s organs arteriosus, and ductus venosus are obliterated at of 2 lb or more per week indicates a problem.
a spontaneous or missed abortion impending undergo the initial readjustment to the birth. Early morning headache is not a classic sign of
can all produce false-negative results. nonpregnant state. 27. B. Uric acid crystals in the urine may produce the PIH.
15. D. The FHR can be auscultated with a fetoscope 22. C. Barbiturates are rapidly transferred across the reddish “brick dust” stain on the diaper. Mucus 34. C. In a missed abortion, there is early fetal
at about 20 week’s gestation. FHR usually is placental barrier, and lack of an antagonist would not produce a stain. Bilirubin and iron are intrauterine death, and products of conception
ausculatated at the midline suprapubic region makes them generally inappropriate during from hepatic adaptation. are not expelled. The cervix remains closed;
with Doppler ultrasound transducer at 10 to 12 active labor. Neonatal side effects of 28. B. The normal heart rate for a newborn that is there may be a dark brown vaginal discharge,
week’s gestation. FHR, cannot be heard any barbiturates include central nervous system sleeping is approximately 100 beats per minute. negative pregnancy test, and cessation of
earlier than 10 weeks’ gestation. depression, prolonged drowsiness, delayed If the newborn was awake, the normal heart rate uterine growth and breast tenderness. A
16. C. To determine the EDD when the date of the establishment of feeding (e.g. due to poor would range from 120 to 160 beats per minute. threatened abortion is evidenced with cramping
client’s LMP is known use Nagele rule. To the sucking reflex or poor sucking pressure). 29. C. The anterior fontanel is larger in size than the and vaginal bleeding in early pregnancy, with no
first day of the LMP, add 7 days, subtract 3 Tranquilizers are associated with neonatal posterior fontanel. Additionally, the anterior cervical dilation. An incomplete abortion
months, and add 1 year (if applicable) to arrive effects such as hypotonia, hypothermia, fontanel, which is diamond shaped, closes at 18 presents with bleeding, cramping, and cervical
at the EDD as follows: 5 + 7 = 12 (July) minus 3 = generalized drowsiness, and reluctance to feed months, whereas the posterior fontanel, which dilation. An incomplete abortion involves only
4 (April). Therefore, the client’s EDD is April 12. for the first few days. Narcotic analgesic readily is triangular shaped, closes at 8 to 12 weeks. expulsion of part of the products of conception
17. A. When the LMP is unknown, the gestational cross the placental barrier, causing depressive Neither fontanel should appear bulging, which and bleeding occurs with cervical dilation.
age of the fetus is estimated by uterine size or effects in the newborn 2 to 3 hours after may indicate increased intracranial pressure, or 35. A. Multiple gestation is one of the predisposing
position (fundal height). The presence of the intramuscular injection. Regional anesthesia is sunken, which may indicate dehydration. factors that may cause placenta previa. Uterine
uterus in the pelvis indicates less than 12 weeks’ associated with adverse reactions such as 30. B. Blink, cough, sneeze, swallowing and gag anomalies abdominal trauma, and renal or
gestation. At approximately 12 to 14 weeks, the maternal hypotension, allergic or toxic reaction, reflexes are all present at birth and remain vascular disease may predispose a client to
fundus is out of the pelvis above the symphysis or partial or total respiratory failure. unchanged through adulthood. Reflexes such as abruptio placentae.
pubis. The fundus is at the level of the umbilicus 23. D. During the third stage of labor, which begins rooting and stepping subside within the first 36. B. A client with abruptio placentae may exhibit
at approximately 20 weeks’ gestation and with the delivery of the newborn, the nurse year. concealed or dark red bleeding, possibly
reaches the xiphoid at term or 40 weeks. would promote parent-newborn interaction by 31. A. With the babinski reflex, the newborn’s toes reporting sudden intense localized uterine pain.
18. D. Danger signs that require prompt reporting placing the newborn on the mother’s abdomen hyperextend and fan apart from dorsiflexion of The uterus is typically firm to boardlike, and the
leaking of amniotic fluid, vaginal bleeding, and encouraging the parents to touch the the big toe when one side of foot is stroked fetal presenting part may be engaged. Bright
blurred vision, rapid weight gain, and elevated newborn. Collecting a urine specimen and other upward form the heel and across the ball of the red, painless vaginal bleeding, a palpable fetal
blood pressure. Constipation, breast tenderness, laboratory tests is done on admission during the foot. With the startle reflex, the newborn outline and a soft nontender abdomen are
and nasal stuffiness are common discomforts first stage of labor. Assessing uterine abducts and flexes all extremities and may begin manifestations of placenta previa.
associated with pregnancy. contractions every 30 minutes is performed to cry when exposed to sudden movement of 37. D. Abruptio placentae is described as premature
19. B. A rubella titer should be 1:8 or greater. Thurs, during the latent phase of the first stage of loud noise. With the rooting and sucking reflex, separation of a normally implanted placenta
a finding of a titer less than 1:8 is significant, labor. Coaching the client to push effectively is the newborn turns his head in the direction of during the second half of pregnancy, usually with
indicating that the client may not possess appropriate during the second stage of labor. stimulus, opens the mouth, and begins to suck severe hemorrhage. Placenta previa refers to
immunity to rubella. A hematocrit of 33.5% a 24. A. The newborn’s ability to regulate body when the cheeks, lip, or corner of mouth is implantation of the placenta in the lower uterine
white blood cell count of 8,000/mm3, and a 1 temperature is poor. Therefore, placing the touched. With the crawl reflex, the newborn will segment, causing painless bleeding in the third
hour glucose challenge test of 110 g/dl are with newborn under a radiant warmer aids in attempt to crawl forward with both arms and trimester of pregnancy. Ectopic pregnancy refers
normal parameters. maintaining his or her body temperature. to the implantation of the products of
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conception in a site other than the factors may contribute to the mechanical factors pain occurring 10 to 14 days after delivery approximately 6 weeks. Use of a female condom
endometrium. Incompetent cervix is a that cause dystocia. suggest femoral thrombophlebitis. protects the reproductive system from the
conduction characterized by painful dilation of 43. A. With uterine rupture, the client is at risk for 49. B. Manifestations of cystitis include, frequency, introduction of semen or spermicides into the
the cervical os without uterine contractions. hypovolemic shock. Therefore, the priority is to urgency, dysuria, hematuria nocturia, fever, and vagina and may be used after childbirth. Oral
38. B. Hyperstimulation of the uterus such as with prevent and limit hypovolemic shock. Immediate suprapubic pain. Dehydration, hypertension, and contraceptives may be started within the first
oxytocin during the induction of labor may result steps should include giving oxygen, replacing lost chills are not typically associated with cystitis. postpartum week to ensure suppression of
in tetanic contractions prolonged to more than fluids, providing drug therapy as needed, High fever chills, flank pain, nausea, vomiting, ovulation. For the couple who has determined
90seconds, which could lead to such evaluating fetal responses and preparing for dysuria, and frequency are associated with the female’s fertile period, using the rhythm
complications as fetal distress, abruptio surgery. Obtaining blood specimens, instituting pvelonephritis. method, avoidance of intercourse during this
placentae, amniotic fluid embolism, laceration of complete bed rest, and inserting a urinary 50. C. According to statistical reports, between 50% period, is safe and effective.
the cervix, and uterine rupture. Weak catheter are necessary in preparation for surgery and 80% of all new mothers report some form of 54. C. An IUD may increase the risk of pelvic
contractions would not occur. Pain, bright red to remedy the rupture. postpartum blues. The ranges of 10% to 40%, inflammatory disease, especially in women with
vaginal bleeding, and increased restlessness and 44. B. The immediate priority is to minimize 30% to 50%, and 25% to 70% are incorrect. more than one sexual partner, because of the
anxiety are not associated with pressure on the cord. Thus the nurse’s initial 51. B. Regular timely ingestion of oral contraceptives increased risk of sexually transmitted infections.
hyperstimulation. action involves placing the client on bed rest and is necessary to maintain hormonal levels of the An UID should not be used if the woman has an
39. C. A key point to consider when preparing the then placing the client in a knee-chest position drugs to suppress the action of the active or chronic pelvic infection, postpartum
client for a cesarean delivery is to modify the or lowering the head of the bed, and elevating hypothalamus and anterior pituitary leading to infection, endometrial hyperplasia or carcinoma,
preoperative teaching to meet the needs of the maternal hips on a pillow to minimize the inappropriate secretion of FSH and LH. or uterine abnormalities. Age is not a factor in
either a planned or emergency cesarean birth, pressure on the cord. Monitoring maternal vital Therefore, follicles do not mature, ovulation is determining the risks associated with IUD use.
the depth and breadth of instruction will depend signs and FHR, notifying the physician and inhibited, and pregnancy is prevented. The Most IUD users are over the age of 30. Although
on circumstances and time available. Allowing preparing the client for delivery, and wrapping estrogen content of the oral site contraceptive there is a slightly higher risk for infertility in
the mother’s support person to remain with her the cord with sterile saline soaked warm gauze may cause the nausea, regardless of when the women who have never been pregnant, the IUD
as much as possible is an important concept, are important. But these actions have no effect pill is taken. Side effects and drug interactions is an acceptable option as long as the risk-
although doing so depends on many variables. on minimizing the pressure on the cord. may occur with oral contraceptives regardless of benefit ratio is discussed. IUDs may be inserted
Arranging for necessary explanations by various 45. D. Postpartum hemorrhage is defined as blood the time the pill is taken. immediately after delivery, but this is not
staff members to be involved with the client’s loss of more than 500 ml following birth. Any 52. C. Condoms, when used correctly and recommended because of the increased risk and
care is a nursing responsibility. The nurse is amount less than this not considered consistently, are the most effective rate of expulsion at this time.
responsible for reinforcing the explanations postpartum hemorrhage. contraceptive method or barrier against 55. C. During the third trimester, the enlarging
about the surgery, expected outcome, and type 46. D. With mastitis, injury to the breast, such as bacterial and viral sexually transmitted uterus places pressure on the intestines. This
of anesthetic to be used. The obstetrician is overdistention, stasis, and cracking of the infections. Although spermicides kill sperm, they coupled with the effect of hormones on smooth
responsible for explaining about the surgery and nipples, is the primary predisposing factor. do not provide reliable protection against the muscle relaxation causes decreased intestinal
outcome and the anesthesiology staff is Epidemic and endemic infections are probable spread of sexually transmitted infections, motility (peristalsis). Increasing fiber in the diet
responsible for explanations about the type of sources of infection for mastitis. Temporary especially intracellular organisms such as HIV. will help fecal matter pass more quickly through
anesthesia to be used. urinary retention due to decreased perception of Insertion and removal of the diaphragm along the intestinal tract, thus decreasing the amount
40. A. Preterm labor is best described as labor that the urge to void is a contributory factor to the with the use of the spermicides may cause of water that is absorbed. As a result, stool is
begins after 20 weeks’ gestation and before 37 development of urinary tract infection, not vaginal irritations, which could place the client at softer and easier to pass. Enemas could
weeks’ gestation. The other time periods are mastitis. risk for infection transmission. Male sterilization precipitate preterm labor and/or electrolyte loss
inaccurate. 47. D. Thrombophlebitis refers to an inflammation eliminates spermatozoa from the ejaculate, but and should be avoided. Laxatives may cause
41. B. PROM can precipitate many potential and of the vascular endothelium with clot formation it does not eliminate bacterial and/or viral preterm labor by stimulating peristalsis and may
actual problems; one of the most serious is the on the wall of the vessel. Blood components microorganisms that can cause sexually interfere with the absorption of nutrients. Use
fetus loss of an effective defense against combining to form an aggregate body describe a transmitted infections. for more than 1 week can also lead to laxative
infection. This is the client’s most immediate thrombus or thrombosis. Clots lodging in the 53. A. The diaphragm must be fitted individually to dependency. Liquid in the diet helps provide a
need at this time. Typically, PROM occurs about pulmonary vasculature refers to pulmonary ensure effectiveness. Because of the changes to semisolid, soft consistency to the stool. Eight to
1 hour, not 4 hours, before labor begins. Fetal embolism; in the femoral vein, femoral the reproductive structures during pregnancy ten glasses of fluid per day are essential to
viability and gestational age are less immediate thrombophlebitis. and following delivery, the diaphragm must be maintain hydration and promote stool
considerations that affect the plan of care. 48. C. Classic symptoms of DVT include muscle pain, refitted, usually at the 6 weeks’ examination evacuation.
Malpresentation and an incompetent cervix may the presence of Homans sign, and swelling of the following childbirth or after a weight loss of 15 56. D. To ensure adequate fetal growth and
be causes of PROM. affected limb. Midcalf pain, tenderness, and lbs or more. In addition, for maximum development during the 40 weeks of a
42. B. Dystocia is difficult, painful, prolonged labor redness, along the vein reflect superficial effectiveness, spermicidal jelly should be placed pregnancy, a total weight gain 25 to 30 pounds is
due to mechanical factors involving the fetus thrombophlebitis. Chills, fever and malaise in the dome and around the rim. However, recommended: 1.5 pounds in the first 10 weeks;
(passenger), uterus (powers), pelvis (passage), or occurring 2 weeks after delivery reflect pelvic spermicidal jelly should not be inserted into the 9 pounds by 30 weeks; and 27.5 pounds by 40
psyche. Nutritional, environment, and medical thrombophlebitis. Chills, fever, stiffness and vagina until involution is completed at weeks. The pregnant woman should gain less
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weight in the first and second trimester than in pregnant women and especially for diabetic the assessment by elevating the uterus and caused by retained placental fragments or
the third. During the first trimester, the client women, because it burns up glucose, thus displacing to the side of the midline. Vital sign bleeding disorders. Lochia rubra is the normal
should only gain 1.5 pounds in the first 10 decreasing blood sugar. However, dietary intake, assessment is not necessary unless an dark red discharge occurring in the first 2 to 3
weeks, not 1 pound per week. A weight gain of ½ not exercise, is the priority. All pregnant women abnormality in uterine assessment is identified. days after delivery, containing epithelial cells,
pound per week would be 20 pounds for the with diabetes should have periodic monitoring Uterine assessment should not cause acute pain erythrocyes, leukocytes and decidua. Lochia
total pregnancy, less than the recommended of serum glucose. However, those with that requires administration of analgesia. serosa is a pink to brownish serosanguineous
amount. gestational diabetes generally do not need daily Ambulating the client is an essential component discharge occurring from 3 to 10 days after
57. B. To calculate the EDD by Nagele’s rule, add 7 glucose monitoring. The standard of care of postpartum care, but is not necessary prior to delivery that contains decidua, erythrocytes,
days to the first day of the last menstrual period recommends a fasting and 2-hour postprandial assessment of the uterus. leukocytes, cervical mucus, and microorganisms.
and count back 3 months, changing the year blood sugar level every 2 weeks. 65. A. Feeding more frequently, about every 2 Lochia alba is an almost colorless to yellowish
appropriately. To obtain a date of September 27, 61. C. After 20 weeks’ gestation, when there is a hours, will decrease the infant’s frantic, vigorous discharge occurring from 10 days to 3 weeks
7 days have been added to the last day of the rapid weight gain, preeclampsia should be sucking from hunger and will decrease breast after delivery and containing leukocytes,
LMP (rather than the first day of the LMP), plus 4 suspected, which may be caused by fluid engorgement, soften the breast, and promote decidua, epithelial cells, fat, cervical mucus,
months (instead of 3 months) were counted retention manifested by edema, especially of the ease of correct latching-on for feeding. Narcotics cholesterol crystals, and bacteria.
back. To obtain the date of November 7, 7 days hands and face. The three classic signs of administered prior to breast feeding are passed 68. A. The data suggests an infection of the
have been subtracted (instead of added) from preeclampsia are hypertension, edema, and through the breast milk to the infant, causing endometrial lining of the uterus. The lochia may
the first day of LMP plus November indicates proteinuria. Although urine is checked for excessive sleepiness. Nipple soreness is not be decreased or copious, dark brown in
counting back 2 months (instead of 3 months) glucose at each clinic visit, this is not the priority. severe enough to warrant narcotic analgesia. All appearance, and foul smelling, providing further
from January. To obtain the date of December Depression may cause either anorexia or postpartum clients, especially lactating mothers, evidence of a possible infection. All the client’s
27, 7 days were added to the last day of the LMP excessive food intake, leading to excessive should wear a supportive brassiere with wide data indicate a uterine problem, not a breast
(rather than the first day of the LMP) and weight gain or loss. This is not, however, the cotton straps. This does not, however, prevent problem. Typically, transient fever, usually
December indicates counting back only 1 month priority consideration at this time. Weight gain or reduce nipple soreness. Soaps are drying to 101ºF, may be present with breast
(instead of 3 months) from January. thought to be caused by excessive food intake the skin of the nipples and should not be used engorgement. Symptoms of mastitis include
58. D. The client has been pregnant four times, would require a 24-hour diet recall. However, on the breasts of lactating mothers. Dry nipple influenza-like manifestations. Localized infection
including current pregnancy (G). Birth at 38 excessive intake would not be the primary skin predisposes to cracks and fissures, which of an episiotomy or C-section incision rarely
weeks’ gestation is considered full term (T), consideration for this client at this time. can become sore and painful. causes systemic symptoms, and uterine
while birth form 20 weeks to 38 weeks is 62. B. Cramping and vaginal bleeding coupled with 66. D. A weak, thready pulse elevated to 100 BPM involution would not be affected. The client data
considered preterm (P). A spontaneous abortion cervical dilation signifies that termination of the may indicate impending hemorrhagic shock. An do not include dysuria, frequency, or urgency,
occurred at 8 weeks (A). She has two living pregnancy is inevitable and cannot be increased pulse is a compensatory mechanism of symptoms of urinary tract infections, which
children (L). prevented. Thus, the nurse would document an the body in response to decreased fluid volume. would necessitate assessing the client’s urine.
59. B. At 12 weeks gestation, the uterus rises out of imminent abortion. In a threatened abortion, Thus, the nurse should check the amount of 69. C. Because of early postpartum discharge and
the pelvis and is palpable above the symphysis cramping and vaginal bleeding are present, but lochia present. Temperatures up to 100.48F in limited time for teaching, the nurse’s priority is
pubis. The Doppler intensifies the sound of the there is no cervical dilation. The symptoms may the first 24 hours after birth are related to the to facilitate the safe and effective care of the
fetal pulse rate so it is audible. The uterus has subside or progress to abortion. In a complete dehydrating effects of labor and are considered client and newborn. Although promoting
merely risen out of the pelvis into the abdominal abortion all the products of conception are normal. Although rechecking the blood pressure comfort and restoration of health, exploring the
cavity and is not at the level of the umbilicus. expelled. A missed abortion is early fetal may be a correct choice of action, it is not the family’s emotional status, and teaching about
The fetal heart rate at this age is not audible intrauterine death without expulsion of the first action that should be implemented in light family planning are important in
with a stethoscope. The uterus at 12 weeks is products of conception. of the other data. The data indicate a potential postpartum/newborn nursing care, they are not
just above the symphysis pubis in the abdominal 63. B. For the client with an ectopic pregnancy, impending hemorrhage. Assessing the uterus for the priority focus in the limited time presented
cavity, not midway between the umbilicus and lower abdominal pain, usually unilateral, is the firmness and position in relation to the umbilicus by early post-partum discharge.
the xiphoid process. At 12 weeks the FHR would primary symptom. Thus, pain is the priority. and midline is important, but the nurse should 70. C. Heat loss by radiation occurs when the
be difficult to auscultate with a fetoscope. Although the potential for infection is always check the extent of vaginal bleeding first. Then it infant’s crib is placed too near cold walls or
Although the external electronic fetal monitor present, the risk is low in ectopic pregnancy would be appropriate to check the uterus, which windows. Thus placing the newborn’s crib close
would project the FHR, the uterus has not risen because pathogenic microorganisms have not may be a possible cause of the hemorrhage. to the viewing window would be least effective.
to the umbilicus at 12 weeks. been introduced from external sources. The 67. D. Any bright red vaginal discharge would be Body heat is lost through evaporation during
60. A. Although all of the choices are important in client may have a limited knowledge of the considered abnormal, but especially 5 days after bathing. Placing the infant under the radiant
the management of diabetes, diet therapy is the pathology and treatment of the condition and delivery, when the lochia is typically pink to warmer after bathing will assist the infant to be
mainstay of the treatment plan and should will most likely experience grieving, but this is brownish. Lochia rubra, a dark red discharge, is rewarmed. Covering the scale with a warmed
always be the priority. Women diagnosed with not the priority at this time. present for 2 to 3 days after delivery. Bright red blanket prior to weighing prevents heat loss
gestational diabetes generally need only diet 64. D. Before uterine assessment is performed, it is vaginal bleeding at this time suggests late through conduction. A knit cap prevents heat
therapy without medication to control their essential that the woman empty her bladder. A postpartum hemorrhage, which occurs after the loss from the head a large head, a large body
blood sugar levels. Exercise, is important for all full bladder will interfere with the accuracy of first 24 hours following delivery and is generally surface area of the newborn’s body.
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71. B. A fractured clavicle would prevent the normal cord falls off and the stump has completely been used as the time frame for resuming sexual 87. C. Breathing techniques can raise the pain
Moro response of symmetrical sequential healed. activity, but it may be resumed earlier. threshold and reduce the perception of pain.
extension and abduction of the arms followed by 76. B. To determine the amount of formula needed, 81. C. The middle third of the vastus lateralis is the They also promote relaxation. Breathing
flexion and adduction. In talipes equinovarus do the following mathematical calculation. 3 kg x preferred injection site for vitamin K techniques do not eliminate pain, but they can
(clubfoot) the foot is turned medially, and in 120 cal/kg per day = 360 calories/day feeding q 4 administration because it is free of blood vessels reduce it. Positioning, not breathing, increases
plantar flexion, with the heel elevated. The feet hours = 6 feedings per day = 60 calories per and nerves and is large enough to absorb the uteroplacental perfusion.
are not involved with the Moro reflex. feeding: 60 calories per feeding; 60 calories per medication. The deltoid muscle of a newborn is 88. A. The client’s labor is hypotonic. The nurse
Hypothyroiddism has no effect on the primitive feeding with formula 20 cal/oz = 3 ounces per not large enough for a newborn IM injection. should call the physical and obtain an order for
reflexes. Absence of the Moror reflex is the most feeding. Based on the calculation. 2, 4 or 6 Injections into this muscle in a small child might an infusion of oxytocin, which will assist the
significant single indicator of central nervous ounces are incorrect. cause damage to the radial nerve. The anterior uterus to contact more forcefully in an attempt
system status, but it is not a sign of increased 77. A. Intrauterine anoxia may cause relaxation of femoris muscle is the next safest muscle to use to dilate the cervix. Administering light sedative
intracranial pressure. the anal sphincter and emptying of meconium in a newborn but is not the safest. Because of would be done for hypertonic uterine
72. B. Hemorrhage is a potential risk following any into the amniotic fluid. At birth some of the the proximity of the sciatic nerve, the gluteus contractions. Preparing for cesarean section is
surgical procedure. Although the infant has been meconium fluid may be aspirated, causing maximus muscle should not be until the child unnecessary at this time. Oxytocin would
given vitamin K to facilitate clotting, the mechanical obstruction or chemical has been walking 2 years. increase the uterine contractions and hopefully
prophylactic dose is often not sufficient to pneumonitis. The infant is not at increased risk 82. D. Bartholin’s glands are the glands on either progress labor before a cesarean would be
prevent bleeding. Although infection is a for gastrointestinal problems. Even though the side of the vaginal orifice. The clitoris is female necessary. It is too early to anticipate client
possibility, signs will not appear within 4 hours skin is stained with meconium, it is noninfectious erectile tissue found in the perineal area above pushing with contractions.
after the surgical procedure. The primary (sterile) and nonirritating. The postterm the urethra. The parotid glands are open into the 89. D. The signs indicate placenta previa and vaginal
discomfort of circumcision occurs during the meconium-stained infant is not at additional risk mouth. Skene’s glands open into the posterior exam to determine cervical dilation would not
surgical procedure, not afterward. Although for bowel or urinary problems. wall of the female urinary meatus. be done because it could cause hemorrhage.
feedings are withheld prior to the circumcision, 78. C. The nurse should use a nonelastic, flexible, 83. D. The fetal gonad must secrete estrogen for the Assessing maternal vital signs can help
the chances of dehydration are minimal. paper measuring tape, placing the zero point on embryo to differentiate as a female. An increase determine maternal physiologic status. Fetal
73. B. The presence of excessive estrogen and the superior border of the symphysis pubis and in maternal estrogen secretion does not effect heart rate is important to assess fetal well-being
progesterone in the maternal-fetal blood stretching the tape across the abdomen at the differentiation of the embryo, and maternal and should be done. Monitoring the contractions
followed by prompt withdrawal at birth midline to the top of the fundus. The xiphoid and estrogen secretion occurs in every pregnancy. will help evaluate the progress of labor.
precipitates breast engorgement, which will umbilicus are not appropriate landmarks to use Maternal androgen secretion remains the same 90. D. A complete placenta previa occurs when the
spontaneously resolve in 4 to 5 days after birth. when measuring the height of the fundus as before pregnancy and does not effect placenta covers the opening of the uterus, thus
The trauma of the birth process does not cause (McDonald’s measurement). differentiation. Secretion of androgen by the blocking the passageway for the baby. This
inflammation of the newborn’s breast tissue. 79. B. Women hospitalized with severe fetal gonad would produce a male fetus. response explains what a complete previa is and
Newborns do not have breast malignancy. This preeclampsia need decreased CNS stimulation to 84. A. Using bicarbonate would increase the amount the reason the baby cannot come out except by
reply by the nurse would cause the mother to prevent a seizure. Seizure precautions provide of sodium ingested, which can cause cesarean delivery. Telling the client to ask the
have undue anxiety. Breast tissue does not environmental safety should a seizure occur. complications. Eating low-sodium crackers physician is a poor response and would increase
hypertrophy in the fetus or newborns. Because of edema, daily weight is important but would be appropriate. Since liquids can increase the patient’s anxiety. Although a cesarean would
74. D. The first 15 minutes to 1 hour after birth is not the priority. Preclampsia causes vasospasm nausea avoiding them in the morning hours help to prevent hemorrhage, the statement does
the first period of reactivity involving respiratory and therefore can reduce utero-placental when nausea is usually the strongest is not explain why the hemorrhage could occur.
and circulatory adaptation to extrauterine life. perfusion. The client should be placed on her left appropriate. Eating six small meals a day would With a complete previa, the placenta is covering
The data given reflect the normal changes during side to maximize blood flow, reduce blood keep the stomach full, which often decrease all the cervix, not just most of it.
this time period. The infant’s assessment data pressure, and promote diuresis. Interventions to nausea. 91. B. With a face presentation, the head is
reflect normal adaptation. Thus, the physician reduce stress and anxiety are very important to 85. B. Ballottement indicates passive movement of completely extended. With a vertex
does not need to be notified and oxygen is not facilitate coping and a sense of control, but the unengaged fetus. Ballottement is not a presentation, the head is completely or partially
needed. The data do not indicate the presence seizure precautions are the priority. contraction. Fetal kicking felt by the client flexed. With a brow (forehead) presentation, the
of choking, gagging or coughing, which are signs 80. C. Cessation of the lochial discharge signifies represents quickening. Enlargement and head would be partially extended.
of excessive secretions. Suctioning is not healing of the endometrium. Risk of hemorrhage softening of the uterus is known as Piskacek’s 92. D. With this presentation, the fetal upper torso
necessary. and infection are minimal 3 weeks after a sign. and back face the left upper maternal abdominal
75. B. Application of 70% isopropyl alcohol to the normal vaginal delivery. Telling the client 86. B. Chadwick’s sign refers to the purple-blue tinge wall. The fetal heart rate would be most audible
cord minimizes microorganisms (germicidal) and anytime is inappropriate because this response of the cervix. Braxton Hicks contractions are above the maternal umbilicus and to the left of
promotes drying. The cord should be kept dry does not provide the client with the specific painless contractions beginning around the 4th the middle. The other positions would be
until it falls off and the stump has healed. information she is requesting. Choice of a month. Goodell’s sign indicates softening of the incorrect.
Antibiotic ointment should only be used to treat contraceptive method is important, but not the cervix. Flexibility of the uterus against the cervix 93. C. The greenish tint is due to the presence of
an infection, not as a prophylaxis. Infants should specific criteria for safe resumption of sexual is known as McDonald’s sign. meconium. Lanugo is the soft, downy hair on the
not be submerged in a tub of water until the activity. Culturally, the 6-weeks’ examination has shoulders and back of the fetus. Hydramnios
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represents excessive amniotic fluid. Vernix is the MATERNITY NURSING Part 2 months pregnant. Which of Duvall’s family life
white, cheesy substance covering the fetus. stages is the family currently experiencing?
94. D. In a breech position, because of the space 1. Suppose Melissa Chung asks you whether a. Pregnancy stage
between the presenting part and the cervix, maternal child health nursing is a profession. b. Preschool stage
prolapse of the umbilical cord is common. What qualifies an activity as a profession? c. School-age stage
Quickening is the woman’s first perception of a. Members supervise other people d. Launching stage
fetal movement. Ophthalmia neonatorum b. Members use a distinct body of knowledge
usually results from maternal gonorrhea and is c. Members enjoy good working conditions 7. While she is in the hospital, Carmela makes the
conjunctivitis. Pica refers to the oral intake of d. Members receive relatively high pay following statements. Which is the best example
nonfood substances. of stereotyping?
95. A. Dizygotic (fraternal) twins involve two ova 2. Nursing is changing because social change a. My doctor is funny; he tells jokes and makes me
fertilized by separate sperm. Monozygotic affects care. Which of the following is a trend laugh.
(identical) twins involve a common placenta, that is occurring in nursing because of social b. I’m glad I’m Batangueño because all
same genotype, and common chorion. change? Batangueños are smart.
96. C. The zygote is the single cell that reproduces a. So many children are treated in ambulatory c. I’m sure my leg will heal quickly; I’m overall
itself after conception. The chromosome is the units that nurses are hardly needed healthy.
material that makes up the cell and is gained b. Immunizations are no longer needed for d. I like foods in Batangas, although not if it tastes
from each parent. Blastocyst and trophoblast are infectious diseases too spicy.
later terms for the embryo after zygote. c. The use of skilled technology has made
97. D. Prepared childbirth was the direct result of nursing care more complex 8. Monet Rivera tells you she used to wrry because
the 1950’s challenging of the routine use of d. Pregnant women are so healthy today that she developed breasts later than most of her
analgesic and anesthetics during childbirth. The they rarely need prenatal care friends. Breast development is termed:
LDRP was a much later concept and was not a a. Adrenarche
direct result of the challenging of routine use of 3. The best description if the family nurse b. Mamarche
analgesics and anesthetics during childbirth. practitioner role is c. Thelarche
Roles for nurse midwives and clinical nurse a. To give bedside care to critically ill family d. Menarche
specialists did not develop from this challenge. members
98. C. The ischial spines are located in the mid-pelvic b. To supervise the health of children up to age 9. Suppose Jaypee Manalo tells you that he is
region and could be narrowed due to the 18 years considering a vasectomy after the birth of his
previous pelvic injury. The symphysis pubis, c. To provide health supervision for families new child. Vasectomy is the incision of which
sacral promontory, and pubic arch are not part d. To supervise women during pregnancy organ?
of the mid-pelvis. a. Testes
99. B. Variations in the length of the menstrual cycle 4. The Delos Reyes family was a single-parent one b. Vas deferens
are due to variations in the proliferative phase. before Mrs. Delos Reyes remarried. What is a c. Fallopian tube
The menstrual, secretory and ischemic phases common concern of single-parent families? d. Epididymis
do not contribute to this variation. a. Too many people give advice
100. B. Testosterone is produced by the b. Finances are inadequate 10. On physical examination, Monet Rivera is found
Leyding cells in the seminiferous tubules. c. Children miss many days of school to have cystocele. A cystocele is:
Follicle-stimulating hormone and leuteinzing d. Children don’t know any other family like theirs a. A sebaceous cyst arising from a vulvar fold
hormone are released by the anterior pituitary b. Protrusion of the intestine into the vagina
gland. The hypothalamus is responsible for 5. Mrs. Delos Reyes serves many roles in her c. Prolapse of the uterus and cervix into the vagina
releasing gonadotropin-releasing hormone. family. If, when you talk to Veronica, her d. Herniation of the bladder into the vaginal wall
daughter, she interrupts to say, “Don’t tell our
family secrets,” she is fulfilling what family role? 11. Monet Rivera typically has a menstrual cycle of
a. Decision-maker 34 days. She tells you she had coitus on days 8,
b. Gatekeeper 10, 15, and 20 of her last cycle. Which is the day
c. Problem-solver on which she most likely conceived?
d. Bread-earner a. The 8th day
b. The 10th day
6. The Delos Reyes family consists of two parents; c. Day 15
Veronica, 12; and Paolo, 2. Mrs. Delos Reyes is 5 d. Day 20
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12. The Manalo’s neighbor Cahrell is a woman who 17. Roseann, 17 years old, asks you how a tubal d. Donor sperm are injected intraabdominally into d. Wrinkles on soles of the feet
has sex with women. Another term for this ligation prevents pregnancy. Which would be the each ovary
sexual orientation is best answer? 27. Rizalyn asks how much longer her doctor will
a. Lesbian a. Sperm can no longer reach the ova because 22. Guadalupe Atienza is having a gamete refer to the baby inside her as an embryo. What
b. Celibate fallopian tubes are blocked intrafallopian transfer (GIFT) procedure. What would be your best explanation?
c. Gay b. Sperm can not enter the uterus because the makes her a good candidate for this procedure? a. This term is used during the time before
d. Voyeur cervical entrance is blocked a. She has patent fallopian tubes, so fertilized ova fertilization
c. Prostaglandins released from the cut fallopian can be implanted into them b. Her baby will be a fetus as soon as the placenta
13. Suppose Roseann, 17 years old, tells you that tubes can kill sperm b. She is Rh negative, a necessary stipulation to forms
she wants to use fertility awareness method of d. The ovary no longer releases ova as there is no rule out Rh incompatibility c. After the 20th week of pregnancy, the baby is
contraception. How will she determine her where for them to go c. She has a normal uterus, so sperm can be called zygote
fertile days? injected through the cervix into it d. From the time of implantation until 5 to 8
a. She will notice that she feels hot, as if she has an 18. The Atienzas are a couple undergoing testing for d. Her husband is taking sildenafil (Viagra), so all weeks, the baby is an embryo
elevated temperature infertility. Infertility is said to exist when: his perm will be motile
b. She should assess whether her cervical mucus is a. A couple has been trying to conceive for 1 year 28. Rizalyn is worried that her baby will be born with
thin and watery b. A woman has no children 23. Jean Suarez is pregnant with her first child. Her congenital heart disease. What assessment of a
c. She should monitor her emotions for sudden c. A woman has no uterus phenotype refers to: fetus at birth is important to help detect
anger or crying d. A couple has wanted a child for 6 months a. Her concept of herself as male or female congenital heart defects?
d. She should assess whether her breasts feels b. Whether she has 46 chromosomes or not a. Assessing whether the Wharton’s jelly if the cord
sensitive to cool air 19. Guadalupe Atienza is diagnosed as having c. Her actual genetic composition has a pH higher than 7.2
endometriosis. This condition interferes with d. Her outward appearance b. Assessing whether the umbilical cord has two
14. Suppose Roseann, 17 years old, chooses to use a fertility because: arteries and one vein
combination oral contraceptive (COC) as her a. The ovaries stop producing adequate estrogen 24. Jean Suarez is a balanced translocation carrier c. Measuring the length of the cord to be certain
family planning method. What is a danger sign of b. The uterine cervix becomes inflamed and for Down syndrome. This term means that: that it is longer than three feet
COCs you would ask her to report? swollen a. All of her children will be born with some d. Determining that the color of the umbilical cord
a. A stuffy or runny nose c. Pressure on the pituitary leads to decreased FSH aspects of Down syndrome is not green
b. Arthritis-like symptoms levels b. All of her female and none of her male children
c. Slight weight gain d. Endometrial implants can block the fallopian will have Down syndrome 29. Rizalyn asks you why her doctor is concerned
d. Migraine headache tubes c. She has a greater than average chance a child about whether her fetus us producing surfactant
will have Down syndrome or not. Your best answer would be:
15. Suppose Roseann, 17 years old, chooses 20. Guadalupe Atienza is scheduled to have a d. It is impossible for any of her children to be born a. Surfactant keeps lungs from collapsing on
subcutaneous implants (Norplant) as her hysterosalpingogram. Which of the following with Down syndrome expiration, and thus aids newborn breathing
method of reproductive life planning. How long instructions would you give her regarding this b. Surfactant is produced by the fetal liver, so its
will these implants be effective? procedure? 25. Jean Suarez was told at a genetic counseling precursor reveals liver maturity
a. One month a. She may feel some mild cramping when the dye session tat she is a balanced translocation carrier c. Surfactant is the precursor to IgM antibody
b. 12 months is inserted for Down syndrome. What would be your best production, so it prevents infection
c. Five years b. The sonogram of the uterus will reveal any action regarding this information? d. Surfactant reveals mature kidney function, as it
d. 10 years tumors present a. Be certain all of her family understand what this is produced by kidney glomeruli
c. She will not be able to conceive for three means
16. Roseann, 17 years old, wants to try female months after the procedure b. Discuss the cost of various abortion techniques 30. Rizalyn is scheduled to have an ultrasound
condoms as her reproductive life planning d. May women experience mild bleeding as an with Jean examination. What instruction would you give
method. Which instruction would you give her? aftereffect c. Be sure Jean knows she should not have any her before her examination?
a. The hormone the condom releases may cause more children a. Void immediately before the procedure to
mild weight gain. 21. Ruel Marasigan asks you what artificial d. Ask Jean is she has any questions that you could reduce your bladder size
b. She should insert the condom before any penile insemination by donor entails. Which would be answer for her b. The intravenous fluid infused to dilate your
penetration your best answer? uterus does not hurt the fetus
c. She should coat the condom with a spermicide a. Artificial sperm are injected vaginally to test 26. Jean Suarez’s child is born with Down Syndrome. c. You will need to drink at least 3 glasses of fluid
before use tubal patency What is a common physical feature of newborn before the procedure
d. Female condoms, unlike male condoms, can be b. Donor sperm are introduced vaginally into the with this disorder? d. You can have medicine for pain for any
reused. uterus of the cervix a. Spastic and stiff muscles contractions caused by the test
c. The husband’s sperm is administered b. Loose skin at back of neck
intravenously weekly c. A white lock of forehead hair
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31. Rizalyn is scheduled to have an amniocentesis to how decreased insulin effectiveness safeguards b. Tell her to bear down slightly as the speculum is d. Witch hazel pads feel cool against swollen
test for fetal maturity. What instruction would the fetus? inserted hemorrhoids
you give her before this procedure? a. Decreased effectiveness prevents the fetus from c. Singing out loud helps, because this pushes
a. Void immediately before the procedure to being hypoglycemic down the diaphragm 45. Vanna has ankle edema by the end of each day.
reduce your bladder size b. If insulin is ineffective it cannot cross the d. She should breathe slowly and evenly during the Which statement by her would reveal that she
b. The x-ray used to reveal your fetus’ position has placenta and harm the fetus exam understands what causes this?
no long-term effects c. The lessened action prevents the fetus from a. “I know this is a beginning complication; I’ll call
c. The intravenous fluid infused to dilate your gaining too much weight 41. Riza has pelvic measurements taken. What size my doctor tonight.”
uterus does not hurt the fetus d. The mother, not the fetus, is guarded by this should the ischial tuberosity diameter be to be b. “I understand this is from eating too much salt;
d. No more amniotic fluid forms afterward, which decreased insulin action considered adequate? I’ll restrict that more.”
is why only a small amount is removed a. 6 cm c. “I’ll rest in a Sims’ position to take pressure off
37. Riza Cua feels well. She asks you why she needs b. Twice the width of the conjugate diameter lower extremity veins.”
32. Bernadette sometimes feels ambivalent about to come for prenatal care The best reason for c. 11 cm d. “I’ll walk for half an hour every day to relieve
being pregnant. What is the psychological task her to receive regular care is: d. Half the width of the symphysis pubis this; I’ll try walking more.”
you’d like to see her complete during the first a. Discovering allergies can help eliminate early
trimester of pregnancy? birth Situation: One of the nursing roles in caring for the
a. View morning sickness as tolerable b. It helps document how many pregnancies occur pregnant family is promoting fetal and maternal health
b. Accept the fact that she’s pregnant each year
c. Accept the fact that a baby is growing inside her c. It provides time for education about pregnancy 42. Which statement by Vanna Delgado would alert
d. Choose a name for the baby and birth you that she needs more teaching about safe
d. It determines whether pregnancies today are practices during pregnancy?
33. Bernadette is aware that she’s been showing planned or not a. “I take either a shower or tub bath, because I
some narcissism since becoming pregnant. know both are safe.”
Which of her actions best describes narcissism? 38. Why is it important to ask Riza about past b. “I wash my breasts with clear water, not with
a. Her skin feels “pulled thin” across her abdomen surgery on a pregnancy health history? soap daily.”
b. Her thoughts tend to be mainly about herself a. To test her recent and long-term memory c. “I’m glad I don’t have to ask my boyfriend to use
c. She feels a need to sleep a lot more than usual b. Adhesions from surgery could limit uterine condoms anymore.”
d. She often feels “numb” or as if she’s taken a growth d. “I’m wearing low-heeled shoes to try and avoid
narcotic c. To assess she could be allergic to any medication backache.”
d. To determine if she has effective heath
34. Bernadette did a urine pregnancy test but was insurance 43. Vanna describes her typical day to you. What
surprised to learn that a positive result is not a would alert you that she may need further
sure sign if pregnancy. She asks you what would 39. Riza reports that the palms of her hands are pregnancy advice?
be a positive sign. You tell her would be if: always itchy. You notice scratches on them when a. “I jog rather than walk every time I can for
a. She is having consistent uterine growth you do a physical exam. What is the most likely exercise.”
b. She can feel the fetus move inside her cause of this finding during pregnancy? b. “I always go to sleep on my side, not on my
c. hCG can be found in her bloodstream a. She must have become allergic to dishwashing back.”
d. The fetal heart can be seen on ultrasound soap c. “I pack my lunch in the morning when I’m not so
b. She has an allergy to her fetus and will probably tired.”
35. Bernadette’s doctor told her she had a positive abort d. “I walk around my desk every hour to prevent
Chadwick’s sign. She asks you what this means, c. Her weight gain has stretched the skin over her varicosities.”
and you tell her that: hands
a. Her abdomen is soft and tender d. This is a common reaction to increasing estrogen 44. Vanna tells you that she is developing painful
b. Her uterus has tipped forward levels. hemorrhoids. Advice you would give her would
c. Cervical mucus is clear and sticky be:
d. Her vagina has darkened in color 40. Riza has not had a pelvic exam since she was in a. Take a tablespoon of mineral oil with each of
highschool. What advice would you give her to your meals
36. Bernadette overheard her doctor say that insulin help her relax during her first prenatal pelvic b. Omit fiber from your diet. This will prevent
is not as effective during pregnancy as usual. exam? constipation
That made her worry that she is developing a. Have her take a deep breath and hold it during c. Lie on your stomach daily to drain blood from
diabetes, like her aunt. How would you explain the exam the rectal veins
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Answer for maternity part 2 PEDIATRIC NURSING a. Increased food intake owing to age
b. Underdeveloped abdominal muscles
1. While performing physical assessment of a 12 c. Bowlegged posture
BCCBB month-old, the nurse notes that the infant’s d. Linear growth curve
CBCBD anterior fontanelle is still slightly open. Which of 7. If parents keep a toddler dependent in areas
DABDC the following is the nurse’s most appropriate where he is capable of using skills, the toddle
BAADA action? will develop a sense of which of the following?
BADCD a. Notify the physician immediately a. Mistrust
BDBAC because there is a problem. b. Shame
ABBDD b. Perform an intensive neurologic c. Guilt
ACBDD examination. d. Inferiority
CCADC c. Perform an intensive developmental 8. Which of the following is an appropriate toy for
examination. an 18-month-old?
d. Do nothing because this is a normal a. Multiple-piece puzzle
finding for the age. b. Miniature cars
2. When teaching a mother about introducing solid c. Finger paints
foods to her child, which of the following d. Comic book
indicates the earliest age at which this should be 9. When teaching parents about the child’s
done? readiness for toilet training, which of the
a. 1 month following signs should the nurse instruct them to
b. 2 months watch for in the toddler?
c. 3 months a. Demonstrates dryness for 4 hours
d. 4 months b. Demonstrates ability to sit and walk
3. The infant of a substance-abusing mother is at c. Has a new sibling for stimulation
risk for developing a sense of which of the d. Verbalizes desire to go to the bathroom
following? 10. When teaching parents about typical toddler
a. Mistrust eating patterns, which of the following should be
b. Shame included?
c. Guilt a. Food “jags”
d. Inferiority b. Preference to eat alone
4. Which of the following toys should the nurse c. Consistent table manners
recommend for a 5-month-old? d. Increase in appetite
a. A big red balloon 11. Which of the following suggestions should the
b. A teddy bear with button eyes nurse offer the parents of a 4-year-old boy who
c. A push-pull wooden truck resists going to bed at night?
d. A colorful busy box a. “Allow him to fall asleep in your room,
5. The mother of a 2-month-old is concerned that then move him to his own bed.”
she may be spoiling her baby by picking her up b. “Tell him that you will lock him in his
when she cries. Which of the following would be room if he gets out of bed one more
the nurse’s best response? time.”
a. “ Let her cry for a while before picking c. “Encourage active play at bedtime to tire
her up, so you don’t spoil her” him out so he will fall asleep faster.”
b. “Babies need to be held and cuddled; d. “Read him a story and allow him to play
you won’t spoil her this way” quietly in his bed until he falls asleep.”
c. “Crying at this age means the baby is 12. When providing therapeutic play, which of the
hungry; give her a bottle” following toys would best promote imaginative
d. “If you leave her alone she will learn play in a 4-year-old?
how to cry herself to sleep” a. Large blocks
6. When assessing an 18-month-old, the nurse b. Dress-up clothes
notes a characteristic protruding abdomen. c. Wooden puzzle
Which of the following would explain the d. Big wheels
rationale for this finding?
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13. Which of the following activities, when voiced by c. Inferiority d. “We’ll discuss possible solutions with b. Encouraging adequate intake of iron-rich
the parents following a teaching session about d. Role diffusion him and his counselor.” foods
the characteristics of school-age cognitive 19. Which of the following would be most 23. When developing a teaching plan for a group of c. Assisting with coping with chronic illness
development would indicate the need for appropriate for a nurse to use when describing high school students about teenage pregnancy, d. Administering medications via IM
additional teaching? menarche to a 13-year-old? the nurse would keep in mind which of the injections
a. Collecting baseball cards and marbles a. A female’s first menstruation or following? 29. Which of the following information, when voiced
b. Ordering dolls according to size menstrual “periods” a. The incidence of teenage pregnancies is by the mother, would indicate to the nurse that
c. Considering simple problem-solving b. The first year of menstruation or increasing. she understands home care instructions
options “period” b. Most teenage pregnancies are planned. following the administration of a diphtheria,
d. Developing plans for the future c. The entire menstrual cycle or from one c. Denial of the pregnancy is common early tetanus, and pertussis injection?
14. A hospitalized schoolager states: “I’m not afraid “period” to another on. a. Measures to reduce fever
of this place, I’m not afraid of anything.” This d. The onset of uterine maturation or peak d. The risk for complications during b. Need for dietary restrictions
statement is most likely an example of which of growth pregnancy is rare. c. Reasons for subsequent rash
the following? 20. A 14-year-old boy has acne and according to his 24. When assessing a child with a cleft palate, the d. Measures to control subsequent
a. Regression parents, dominates the bathroom by using the nurse is aware that the child is at risk for more diarrhea
b. Repression mirror all the time. Which of the following frequent episodes of otitis media due to which 30. Which of the following actions by a community
c. Reaction formation remarks by the nurse would be least helpful in of the following? health nurse is most appropriate when noting
d. Rationalization talking to the boy and his parents? a. Lowered resistance from malnutrition multiple bruises and burns on the posterior
15. After teaching a group of parents about accident a. “This is probably the only concern he has b. Ineffective functioning of the Eustachian trunk of an 18-month-old child during a home
prevention for schoolagers, which of the about his body. So don’t worry about it tubes visit?
following statements by the group would or the time he spends on it.” c. Plugging of the Eustachian tubes with a. Report the child’s condition to
indicate the need for more teaching? b. “Teenagers are anxious about how their food particles Protective Services immediately.
a. “Schoolagers are more active and peers perceive them. So they spend a lot d. Associated congenital defects of the b. Schedule a follow-up visit to check for
adventurous than are younger children.” of time grooming.” middle ear. more bruises.
b. “Schoolagers are more susceptible to c. “A teen may develop a poor self-image 25. While performing a neurodevelopmental c. Notify the child’s physician immediately.
home hazards than are younger when experiencing acne. Do you feel this assessment on a 3-month-old infant, which of d. Don nothing because this is a normal
children.” way sometimes?” the following characteristics would be expected? finding in a toddler.
c. “Schoolagers are unable to understand d. “You appear to be keeping your face a. A strong Moro reflex 31. Which of the following is being used when the
potential dangers around them.” well washed. Would you feel b. A strong parachute reflex mother of a hospitalized child calls the student
d. “Schoolargers are less subject to comfortable discussing your cleansing c. Rolling from front to back nurse and states, “You idiot, you have no idea
parental control than are younger method?” d. Lifting of head and chest when prone how to care for my sick child”?
children.” 21. Which of the following should the nurse suspect 26. By the end of which of the following would the a. Displacement
16. Which of the following skills is the most when noting that a 3-year-old is engaging in nurse most commonly expect a child’s birth b. Projection
significant one learned during the schoolage explicit sexual behavior during doll play? weight to triple? c. Repression
period? a. The child is exhibiting normal pre-school a. 4 months d. Psychosis
a. Collecting curiosity b. 7 months 32. Which of the following should the nurse expect
b. Ordering b. The child is acting out personal c. 9 months to note as a frequent complication for a child
c. Reading experiences d. 12 months with congenital heart disease?
d. Sorting c. The child does not know how to play 27. Which of the following best describes parallel a. Susceptibility to respiratory infection
17. A child age 7 was unable to receive the measles, with dolls play between two toddlers? b. Bleeding tendencies
mumps, and rubella (MMR) vaccine at the d. The child is probably developmentally a. Sharing crayons to color separate c. Frequent vomiting and diarrhea
recommended scheduled time. When would the delayed. pictures d. Seizure disorder
nurse expect to administer MMR vaccine? 22. Which of the following statements by the b. Playing a board game with a nurse 33. Which of the following would the nurse do first
a. In a month from now parents of a child with school phobia would c. Sitting near each other while playing for a 3-year-old boy who arrives in the
b. In a year from now indicate the need for further teaching? with separate dolls emergency room with a temperature of 105
c. At age 10 a. “We’ll keep him at home until phobia d. Sharing their dolls with two different degrees, inspiratory stridor, and restlessness,
d. At age 13 subsides.” nurses who is learning forward and drooling?
18. The adolescent’s inability to develop a sense of b. “We’ll work with his teachers and 28. Which of the following would the nurse identify a. Auscultate his lungs and place him in a
who he is and what he can become results in a counselors at school.” as the initial priority for a child with acute mist tent.
sense of which of the following? c. “We’ll try to encourage him to talk lymphocytic leukemia? b. Have him lie down and rest after
a. Shame about his problem.” a. Instituting infection control precautions encouraging fluids.
b. Guilt
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c. Examine his throat and perform a throat c. Marked motor delays 47. Which of the following would the nurse expect
culture d. Gait disability to assess in a child with celiac disease having a
d. Notify the physician immediately and 40. Which of the following assessment findings celiac crisis secondary to an upper respiratory
prepare for intubation. would lead the nurse to suspect Down syndrome infection?
34. Which of the following would the nurse need to in an infant? a. Respiratory distress
keep in mind as a predisposing factor when a. Small tongue b. Lethargy
formulating a teaching plan for child with a b. Transverse palmar crease c. Watery diarrhea
urinary tract infection? c. Large nose d. Weight gain
a. A shorter urethra in females d. Restricted joint movement 48. Which of the following should the nurse do first
b. Frequent emptying of the bladder 41. While assessing a newborn with cleft lip, the after noting that a child with Hirschsprung
c. Increased fluid intake nurse would be alert that which of the following disease has a fever and watery explosive
d. Ingestion of acidic juices will most likely be compromised? diarrhea?
35. Which of the following should the nurse do first a. Sucking ability a. Notify the physician immediately
for a 15-year-old boy with a full leg cast who is b. Respiratory status b. Administer antidiarrheal medications
screaming in unrelenting pain and exhibiting c. Locomotion c. Monitor child ever 30 minutes
right foot pallor signifying compartment d. GI function d. Nothing, this is characteristic of
syndrome? 42. When providing postoperative care for the child Hirschsprung disease
a. Medicate him with acetaminophen. with a cleft palate, the nurse should position the 49. A newborn’s failure to pass meconium within
b. Notify the physician immediately child in which of the following positions? the first 24 hours after birth may indicate which
c. Release the traction a. Supine of the following?
d. Monitor him every 5 minutes b. Prone a. Hirschsprung disease
36. At which of the following ages would the nurse c. In an infant seat b. Celiac disease
expect to administer the varicella zoster vaccine d. On the side c. Intussusception
to child? 43. While assessing a child with pyloric stenosis, the d. Abdominal wall defect
a. At birth nurse is likely to note which of the following? 50. When assessing a child for possible
b. 2 months a. Regurgitation intussusception, which of the following would be
c. 6 months b. Steatorrhea least likely to provide valuable information?
d. 12 months c. Projectile vomiting a. Stool inspection
37. When discussing normal infant growth and d. “Currant jelly” stools b. Pain pattern
development with parents, which of the 44. Which of the following nursing diagnoses would c. Family history
following toys would the nurse suggest as most be inappropriate for the infant with d. Abdominal palpation
appropriate for an 8-month-old? gastroesophageal reflux (GER)?
a. Push-pull toys a. Fluid volume deficit
b. Rattle b. Risk for aspiration
c. Large blocks c. Altered nutrition: less than body
d. Mobile requirements
38. Which of the following aspects of psychosocial d. Altered oral mucous membranes
development is necessary for the nurse to keep 45. Which of the following parameters would the
in mind when providing care for the preschool nurse monitor to evaluate the effectiveness of
child? thickened feedings for an infant with
a. The child can use complex reasoning to gastroesophageal reflux (GER)?
think out situations. a. Vomiting
b. Fear of body mutilation is a common b. Stools
preschool fear c. Uterine
c. The child engages in competitive types d. Weight
of play 46. Discharge teaching for a child with celiac disease
d. Immediate gratification is necessary to would include instructions about avoiding which
develop initiative. of the following?
39. Which of the following is characteristic of a a. Rice
preschooler with mid mental retardation? b. Milk
a. Slow to feed self c. Wheat
b. Lack of speech d. Chicken
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ANSWERS and RATIONALES for PEDIATRIC NURSING decreases, not increases. Toddlers are frightening and potentially hazardous. Vigorous 16. C. The most significant skill learned during the
characteristically bowlegged because the leg activity at bedtime stirs up the child and makes school-age period is reading. During this time
1. D. The anterior fontanelle typically closes muscles must bear the weight of the relatively more difficult to fall asleep. the child develops formal adult articulation
anywhere between 12 to 18 months of age. large trunk. Toddler growth patterns occur in a 12. B. Dress-up clothes enhance imaginative play patterns and learns that words can be arranged
Thus, assessing the anterior fontanelle as still steplike, not linear pattern. and imagination, allowing preschoolers to in structure. Collective, ordering, and sorting,
being slightly open is a normal finding requiring 7. B. According to Erikson, toddlers experience a engage in rich fantasy play. Building blocks and although important, are not most significant
no further action. Because it is normal finding for sense of shame when they are not allowed to wooden puzzles are appropriate for encouraging skills learned.
this age, notifying he physician or performing develop appropriate independence and fine motor development. Big wheels and 17. C. Based on the recommendations of the
additional examinations are inappropriate. autonomy. Infants develop mistrust when their tricycles encourage gross motor development. American Academy of Family Physicians and the
2. D. Solid foods are not recommended before age needs are not consistently gratified. 13. D. The school-aged child is in the stage of American Academy of Pediatrics, the MMR
4 to 6 months because of the sucking reflex and Preschoolers develop guilt when their initiative concrete operations, marked by inductive vaccine should be given at the age of 10 if the
the immaturity of the gastrointestinal tract and needs are not met while schoolagers develop a reasoning, logical operations, and reversible child did not receive it between the ages of 4 to
immune system. Therefore, the earliest age at sense of inferiority when their industry needs concrete thought. The ability to consider the 6 years as recommended. Immunization for
which to introduce foods is 4 months. Any time are not met. future requires formal thought operations, diphtheria and tetanus is required at age 13.
earlier would be inappropriate. 8. C. Young toddlers are still sensorimotor learners which are not developed until adolescence. 18. D. According to Erikson, role diffusion develops
3. A. According to Erikson, infants need to have and they enjoy the experience of feeling Collecting baseball cards and marbles, ordering when the adolescent does not develop a sense
their needs met consistently and effectively to different textures. Thus, finger paints would be dolls by size, and simple problem-solving options of identity and a sense or where he fits in.
develop a sense of trust. An infant whose needs an appropriate toy choice. Multiple-piece toys, are examples of the concrete operational Toddlers develop a sense of shame when they
are consistently unmet or who experiences such as puzzle, are too difficult to manipulate thinking of the schoolager. do not achieve autonomy. Preschoolers develop
significant delays in having them met, such as in and may be hazardous if the pieces are small 14. C. Reaction formation is the schoolager’s typical a sense of guilt when they do not develop a
the case of the infant of a substance-abusing enough to be aspirated. Miniature cars also have defensive response when hospitalized. In sense of initiative. School-age children develop a
mother, will develop a sense of uncertainty, a high potential for aspiration. Comic books are reaction formation, expression of unacceptable sense of inferiority when they do not develop a
leading to mistrust of caregivers and the on too high a level for toddlers. Although they thoughts or behaviors is prevented (or sense of industry.
environment. Toddlers develop a sense of may enjoy looking at some of the pictures, overridden) by the exaggerated expression of 19. A. Menarche refers to the onset of the first
shame when their autonomy needs are not met toddlers are more likely to rip a comic book opposite thoughts or types of behaviors. menstruation or menstrual period and refers
consistently. Preschoolers develop a sense of apart. Regression is seen in toddlers and preshcoolers only to the first cycle. Uterine growth and
guilt when their sense of initiative is thwarted. 9. D. The child must be able to sate the need to go when they retreat or return to an earlier level of broadening of the pelvic girdle occurs before
Schoolagers develop a sense of inferiority when to the bathroom to initiate toilet training. development. Repression refers to the menarche.
they do not develop a sense of industry. Usually, a child needs to be dry for only 2 hours, involuntary blocking of unpleasant feelings and 20. A. Stating that this is probably the only concern
4. D. A busy box facilitates the fine motor not 4 hours. The child also must be able to sit, experiences from one’s awareness. the adolescent has and telling the parents not to
development that occurs between 4 and 6 walk, and squat. A new sibling would most likely Rationalization is the attempt to make excuses worry about it or the time her spends on it shuts
months. Balloons are contraindicated because hinder toilet training. to justify unacceptable feelings or behaviors. off further investigation and is likely to make the
small children may aspirate balloons. Because 10. A. Toddlers become picky eaters, experiencing 15. C. The schoolager’s cognitive level is sufficiently adolescent and his parents feel defensive. The
the button eyes of a teddy bear may detach and food jags and eating large amounts one day and developed to enable good understanding of and statement about peer acceptance and time
be aspirated, this toy is unsafe for children very little the next. A toddler’s food gags express adherence to rules. Thus, schoolagers should be spent in front of the mirror for the development
younger than 3 years. A 5-month-old is too a preference for the ritualism of eating one type able to understand the potential dangers around of self image provides information about the
young to use a push-pull toy. of food for several days at a time. Toddlers them. With growth comes greater freedom and adolescent’s needs to the parents and may help
5. B. Infants need to have their security needs met typically enjoy socialization and limiting others children become more adventurous and daring. to gain trust with the adolescent. Asking the
by being held and cuddled. At 2 months of age, at meal time. Toddlers prefer to feed themselves The school-aged child is also still prone to adolescent how he feels about the acne will
they are unable to make the connection and thus are too young to have table manners. A accidents and home hazards, especially because encourage the adolescent to share his feelings.
between crying and attention. This association toddler’s appetite and need for calories, protein, of increased motor abilities and independence. Discussing the cleansing method shows interest
does not occur until late infancy or early and fluid decrease due to the dramatic slowing Plus the home hazards differ from other age and concern for the adolescent and also can help
toddlerhood. Letting the infant cry for a time of growth rate. groups. These hazards, which are potentially to identify any patient-teaching needs for the
before picking up the infant or leaving the infant 11. D. Preschoolers commonly have fears of the lethal but tempting, may include firearms, adolescent regarding cleansing.
alone to cry herself to sleep interferes with dark, being left alone especially at bedtime, and alcohol, and medications. School-age children 21. B. Preschoolers should be developmentally
meeting the infant’s need for security at this ghosts, which may affect the child’s going to bed begin to internalize their own controls and need incapable of demonstrating explicit sexual
very young age. Infants cry for many reasons. at night. Quiet play and time with parents is a less outside direction. Plus the child is away from behavior. If a child does so, the child has been
Assuming that the child s hungry may cause positive bedtime routine that provides security home more often. Some parental or caregiver exposed to such behavior, and sexual abuse
overfeeding problems such as obesity. and also readies the child for sleep. The child assistance is still needed to answer questions should be suspected. Explicit sexual behavior
6. B. Underdeveloped abdominal musculature should sleep in his own bed. Telling the child and provide guidance for decisions and during doll play is not a characteristic of
gives the toddler a characteristically protruding about locking him in his room will viewed by the responsibilities. preschool development nor symptomatic of
abdomen. During toddlerhood, food intake child as a threat. Additionally, a locked door is
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developmental delay. Whether or nor the child play. Sharing crayons, playing a board game with into the unconscious. Psychosis is a state of capable of making hand-to-hand transfers, large
knows how to play with dolls is irrelevant. a nurse, or sharing dolls with two different being out of touch with reality. blocks would be the most appropriate toy
22. A. The parents need more teaching if they state nurses are all examples of cooperative play. 32. A. Children with congenital heart disease are selection. Push-pull toys would be more
that they will keep the child home until the 28. A. Acute lymphocytic leukemia (ALL) causes more prone to respiratory infections. Bleeding appropriate for the 10 to 12-month-old as he or
phobia subsides. Doing so reinforces the child’s leukopenia, resulting in immunosuppression and tendencies, frequent vomiting, and diarrhea and she begins to cruise the environment. Rattles
feelings of worthlessness and dependency. The increasing the risk of infection, a leading cause seizure disorders are not associated with and mobiles are more appropriate for infants in
child should attend school even during of death in children with ALL. Therefore, the congenital heart disease. the 1 to 3 month age range. Mobiles pose a
resolution of the problem. Allowing the child to initial priority nursing intervention would be to 33. D. The child is exhibiting classic signs of danger to older infants because of possible
verbalize helps the child to ventilate feelings and institute infection control precautions to epiglottitis, always a pediatric emergency. The strangulation.
may help to uncover causes and solutions. decrease the risk of infection. Iron-rich foods physician must be notified immediately and the 38. B. During the preschool period, the child has
Collaboration with the teachers and counselors help with anemia, but dietary iron is not an nurse must be prepared for an emergency mastered a sense of autonomy and goes on to
at school may lead to uncovering the cause of initial intervention. The prognosis of ALL usually intubation or tracheostomy. Further assessment master a sense of initiative. During this period,
the phobia and to the development of solutions. is good. However, later on, the nurse may need with auscultating lungs and placing the child in a the child commonly experiences more fears than
The child should participate and play an active to assist the child and family with coping since mist tent wastes valuable time. The situation is a at any other time. One common fear is fear of
role in developing possible solutions. death and dying may still be an issue in need of possible life-threatening emergency. Having the the body mutilation, especially associated with
23. C. The adolescent who becomes pregnant discussion. Injections should be discouraged, child lie down would cause additional distress painful experiences. The preschool child uses
typically denies the pregnancy early on. Early owing to increased risk from bleeding due to and may result in respiratory arrest. Throat simple, not complex, reasoning, engages in
recognition by a parent or health care provider thrombocytopenia. examination may result in laryngospasm that associative, not competitive, play (interactive
may be crucial to timely initiation of prenatal 29. A. The pertusis component may result in fever could be fatal. and cooperative play with sharing), and is able to
care. The incidence of adolescent pregnancy has and the tetanus component may result in 34. A. In females, the urethra is shorter than in tolerate longer periods of delayed gratification.
declined since 1991, yet morbidity remains high. injection soreness. Therefore, the mother’s males. This decreases the distance for organisms 39. A. Mild mental retardation refers to
Most teenage pregnancies are unplanned and verbalization of information about measures to to travel, thereby increasing the chance of the development disability involving an IQ 50 to 70.
occur out of wedlock. The pregnant adolescent is reduce fever indicates understanding. No dietary child developing a urinary tract infection. Typically, the child is not noted as being
at high risk for physical complications including restrictions are necessary after this injection is Frequent emptying of the bladder would help to retarded, but exhibits slowness in performing
premature labor and low-birth-weight infants, given. A subsequent rash is more likely to be decrease urinary tract infections by avoiding tasks, such as self-feeding, walking, and taking.
high neonatal mortality, iron deficiency anemia, seen 5 to 10 days after receiving the MMR sphincter stress. Increased fluid intake enables Little or no speech, marked motor delays, and
prolonged labor, and fetopelvic disproportion as vaccine, not the diphtheria, pertussis, and the bladder to be cleared more frequently, thus gait disabilities would be seen in more severe
well as numerous psychological crises. tetanus vaccine. Diarrhea is not associated with helping to prevent urinary tract infections. The forms mental retardation.
24. B. Because of the structural defect, children with this vaccine. intake of acidic juices helps to keep the urine pH 40. B. Down syndrome is characterized by the
cleft palate may have ineffective functioning of 30. A. Multiple bruises and burns on a toddler are acidic and thus decrease the chance of flora following a transverse palmar crease (simian
their Eustachian tubes creating frequent bouts signs child abuse. Therefore, the nurse is development. crease), separated sagittal suture, oblique
of otitis media. Most children with cleft palate responsible for reporting the case to Protective 35. B. Compartment syndrome is an emergent palpebral fissures, small nose, depressed nasal
remain well-nourished and maintain adequate Services immediately to protect the child from situation and the physician needs to be notified bridge, high-arched palate, excess and lax skin,
nutrition through the use of proper feeding further harm. Scheduling a follow-up visit is immediately so that interventions can be wide spacing and plantar crease between the
techniques. Food particles do not pass through inappropriate because additional harm may initiated to relieve the increasing pressure and second and big toes, hyperextensible and lax
the cleft and into the Eustachian tubes. There is come to the child if the nurse waits for further restore circulation. Acetaminophen (Tylenol) will joints, large protruding tongue, and muscle
no association between cleft palate and assessment data. Although the nurse should be ineffective since the pain is related to the weakness.
congenial ear deformities. notify the physician, the goal is to initiate increasing pressure and tissue ischemia. The 41. A. Because of the defect, the child will be unable
25. D. A 3-month-old infant should be able to lift the measures to protect the child’s safety. Notifying cast, not traction, is being used in this situation to from the mouth adequately around nipple,
head and chest when prone. The Moro reflex the physician immediately does not initiate the for immobilization, so releasing the traction thereby requiring special devices to allow for
typically diminishes or subsides by 3 months. removal of the child from harm nor does it would be inappropriate. In this situation, specific feeding and sucking gratification. Respiratory
The parachute reflex appears at 9 months. absolve the nurse from responsibility. Multiple action not continued monitoring is indicated. status may be compromised if the child is fed
Rolling from front to back usually is bruises and burns are not normal toddler 36. D. The varicella zoster vaccine (VZV) is a live improperly or during postoperative period,
accomplished at about 5 months. injuries. vaccine given after age 12 months. The first dose Locomotion would be a problem for the older
26. D. A child’s birth weight usually triples by 12 31. B. The mother is using projection, the defense of hepatitis B vaccine is given at birth to 2 infant because of the use of restraints. GI
months and doubles by 4 months. No specific mechanism used when a person attributes his or months, then at 1 to 4 months, and then again at functioning is not compromised in the child with
birth weight parameters are established for 7 or her own undesirable traits to another. 6 to 18 months. DtaP is routinely given at 2, 4, 6, a cleft lip.
9 months. Displacement is the transfer of emotion onto an and 15 to 18 months and a booster at 4 to 6 42. B. Postoperatively children with cleft palate
27. C. Toddlers engaging in parallel play will play unrelated object, such as when the mother years. should be placed on their abdomens to facilitate
near each other, but not with each other. Thus, would kick a chair or bang the door shut. 37. C. Because the 8-month-old is refining his gross drainage. If the child is placed in the supine
when two toddlers sit near each other but play Repression is the submerging of painful ideas motor skills, being able to sit unsupported and position, he or she may aspirate. Using an infant
with separate dolls, they are exhibiting parallel also improving his fine motor skills, probably seat does not facilitate drainage. Side-lying does
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not facilitate drainage as well as the prone inadequate motility in an intestinal segment. COMMUNITY HEALTH NURSING Part 1 disease causation
position. Failure to pass meconium is not associated with C. Immunize nearby communities with Measles
43. C. Projectile vomiting is a key symptom of pyloric celiac disease, intussusception, or abdominal SITUATION : Epidemiology and Vital statistics is a very D. Educate the community in future prevention of similar
stenosis. Regurgitation is seen more commonly wall defect. important tool that a nurse could use in controlling the outbreaks
with GER. Steatorrhea occurs in malabsorption 50. C. Because intussusception is not believed to spread of disease in the community and at the same
disorders such as celiac disease. “Currant jelly” have a familial tendency, obtaining a family time, surveying the impact of the disease on the 6. The main concern of a public health nurse is the
stools are characteristic of intussusception. history would provide the least amount of population and prevent it’s future occurrence. prevention of disease, prolonging of life and promoting
44. D. GER is the backflow of gastric contents into information. Stool inspection, pain pattern, and physical health and efficiency through which of the
the esophagus resulting from relaxation or abdominal palpation would reveal possible 1. It is concerned with the study of factors that influence following?
incompetence of the lower esophageal (cardiac) indicators of intussusception. Current, jelly-like the occurrence and distribution of diseases, defects,
sphincter. No alteration in the oral mucous stools containing blood and mucus are an disability or death which occurs in groups or aggregation A. Use of epidemiological tools and vital health statistics
membranes occurs with this disorder. Fluid indication of intussusception. Acute, episodic of individuals. B. Determine the spread and occurrence of the disease
volume deficit, risk for aspiration, and altered abdominal pain is characteristics of C. Political empowerment and Socio Economic
nutrition are appropriate nursing diagnoses. intussusception. A sausage-shaped mass may be A. Epidemiology Assistance
45. A. Thickened feedings are used with GER to stop palpated in the right upper quadrant. B. Demographics D. Organized Community Efforts
the vomiting. Therefore, the nurse would C. Vital Statistics
monitor the child’s vomiting to evaluate the D. Health Statistics 7. In order to control a disease effectively, which of the
effectiveness of using the thickened feedings. No following must first be known?
relationship exists between feedings and 2. Which of the following is the backbone in disease
characteristics of stools and uterine. If feedings prevention? 1. The conditions surrounding its occurrence
are ineffective, this should be noted before 2. Factors that do not favor its development
there is any change in the child’s weight. A. Epidemiology 3. The condition that do not surround its occurrence
46. C. Children with celiac disease cannot tolerate or B. Demographics 4. Factors that favors its development
digest gluten. Therefore, because of its gluten C. Vital Statistics
content, wheat and wheat-containing products D. Health Statistics A. 1 and 3
must be avoided. Rice, milk, and chicken do not B. 1 and 4
contain gluten and need not be avoided. 3. Which of the following type of research could show C. 2 and 3
47. C. Episodes of celiac crises are precipitated by how community expectations can result in the actual D. 2 and 4
infections, ingestion of gluten, prolonged fasting, provision of services?
or exposure to anticholinergic drugs. Celiac crisis 8. All of the following are uses of epidemiology except:
is typically characterized by severe watery A. Basic Research
diarrhea. Respiratory distress is unlikely in a B. Operational Research A. To study the history of health population and the rise
routine upper respiratory infection. Irritability, C. Action Research and fall of disease
rather than lethargy, is more likely. Because of D. Applied Research B. To diagnose the health of the community and the
the fluid loss associated with the severe watery condition of the people
diarrhea, the child’s weight is more likely to be 4. An outbreak of measles has been reported in C. To provide summary data on health service delivery
decreased. Community A. As a nurse, which of the following is your D. To identify groups needing special attention
48. A. For the child with Hirschsprung disease, fever first action for an Epidemiological investigation?
and explosive diarrhea indicate enterocolitis, a 9. Before reporting the fact of presence of an epidemic,
life-threatening situation. Therefore, the A. Classify if the outbreak of measles is epidemic or just which of the following is of most importance to
physician should be notified immediately. sporadic determine?
Generally, because of the intestinal obstruction B. Report the incidence into the RHU
and inadequate propulsive intestinal movement, C. Determine the first day when the outbreak occurred A. Are the facts complete?
antidiarrheals are not used to treat Hirschsprung D. Identify if it is the disease which it is reported to be B. Is the disease real?
disease. The child is acutely ill and requires C. Is the disease tangible?
intervention, with monitoring more frequently 5. After the epidemiological investigation produced final D. Is it epidemic or endemic?
than every 30 minutes. Hirschsprung disease conclusions, which of the following is your initial step in
typically presents with chronic constipation. your operational procedure during disease outbreak? 10. An unknown epidemic has just been reported in
49. A. Failure to pass meconium within the first 24 Barangay Dekbudekbu. People said that affected person
hours after birth may be an indication of A. Coordinate personnel from Municipal to the National demonstrates hemorrhagic type of fever. You are
Hirschsprung disease, a congenital anomaly level designated now to plan for epidemiological
resulting in mechanical obstruction due to B. Collect pertinent laboratory specimen to confirm investigation. Arrange the sequence of events in
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accordance with the correct outline plan for A. 651

epidemiological investigation. 13. All of the following are function of Nurse Budek in A. NSO B. 541
epidemiology except B. Court of Appeals C. 996
1. Report the presence of dengue C. Municipal Trial Court D. 825
2. Summarize data and conclude the final picture of A. Laboratory Diagnosis D. Local Civil Registrar
epidemic B. Surveillance of disease occurrence 25. These rates are referred to the total living
3. Relate the occurrence to the population group, C. Follow up cases and contacts 20. Acasia just gave birth to Lestat, A healthy baby boy. population, It must be presumed that the total
facilities, food supply and carriers D. Refer cases to hospitals if necessary Who are going to report the birth of Baby Lestat? population was exposed to the risk of occurrence of the
4. Determine if the disease is factual or real E. Isolate cases of communicable disease event.
5. Determine any unusual prevalence of the disease and A. Nurse
its nature; is it epidemic, sporadic, endemic or 14. All of the following are performed in team B. Midwife A. Rate
pandemic? organization except C. OB Gyne B. Ratio
6. Determine onset and the geographical limitation of D. Birth Attendant C. Crude/General Rates
the disease. A. Orientation and demonstration of methodology to be D. Specific Rate
employed 21. In reporting the birth of Baby Lestat, where will he be
A. 4,1,3,5,2,6 B. Area assignments of team members registered? 26. These are used to describe the relationship between
B. 4,1,5,6,3,2 C. Check team’s equipments and paraphernalia two numerical quantities or measures of events without
C. 5,4,6,2,1,3 D. Active case finding and Surveillance A. At the Local Civil Registrar taking particular considerations to the time or place.
D. 5,4,6,1,2,3 B. In the National Statistics Office
E. 1,2,3,4,5,6 15. Which of the following is the final output of data C. In the City Health Department A. Rate
reporting in epidemiological operational procedure? D. In the Field Health Services and Information System B. Ratios
11. In the occurrence of SARS and other pandemics, Main Office C. Crude/General Rate
which of the following is the most vital role of a nurse in A. Recommendation D. Specific Rate
epidemiology? B. Evaluation 22. Deejay, The birth attendant noticed that Lestat has
C. Final Report low set of ears, Micrognathia, Microcephaly and a typical 27. This is the most sensitive index in determining the
A. Health promotion D. Preliminary report cat like cry. What should Deejay do? general health condition of a community since it reflects
B. Disease prevention the changes in the environment and medical conditions
C. Surveillance 16. The office in charge with registering vital facts in the A. Bring Lestat immediately to the nearest hospital of a community
D. Casefinding Philippines is none other than the B. Ask his assistant to call the nearby pediatrician
C. Bring Lestat to the nearest pediatric clinic A. Crude death rate
12. Measles outbreak has been reported in Barangay A. PCSO D. Call a Taxi and together with Acasia, Bring Lestat to B. Infant mortality rate
Bahay Toro, After conducting an epidemiological B PAGCOR the nearest hospital C. Maternal mortality rate
investigation you have confirmed that the outbreak is C. DOH D. Fetal death rate
factual. You are tasked to lead a team of medical D. NSO 23. Deejay would suspect which disorder?
workers for operational procedure in disease outbreak. 28. According to the WHO, which of the following is the
Arrange the correct sequence of events that you must 17. The following are possible sources of Data except: A. Trisomy 21 most frequent cause of death in children underfive
do to effectively contain the disease B. Turners Syndrome worldwide in the 2003 WHO Survey?
A. Experience C. Cri Du Chat
1. Create a final report and recommendation B. Census D. Klinefelters Syndrome A. Neonatal
2. Perform nasopharyngeal swabbing to infected C. Surveys B. Pneumonia
individuals D. Research 24. Deejay could expect which of the following C. Diarrhea
3. Perform mass measles immunization to vulnerable congenital anomaly that would accompany this D. HIV/AIDS
groups 18. This refers to systematic study of vital events such as disorder?
4. Perform an environmental sanitation survey on the births, illnesses, marriages, divorces and deaths 29. In the Philippines, what is the most common cause of
immediate environment A. AVSD death of infants according to the latest survey?
5. Organize your team and Coordinate the personnels A. Epidemiology B. PDA
6. Educate the community on disease transmission B. Demographics C. TOF A. Pneumonia
C. Vital Statistics D. TOGV B. Diarrhea
A. 1,2,3,4,5,6 D. Health Statistics C. Other perinatal condition
B. 6,5,4,3,2,1 26. Which presidential decree orders reporting of births D. Respiratory condition of fetus and newborn
C. 5,6,4,2,3,1 19. In case of clerical errors in your birth certificate, within 30 days after its occurrence?
D. 5,2,3,4,6,1 Where should you go to have it corrected? 30. The major cause of mortality from 1999 up to 2002
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in the Philippines are 4. Death from CVD : 3,029 A. 1/100

5. Deaths under 1 year of age : 23 B. 100% 47. Which of the following is a POINT SOURCE epidemic?
A. Diseases of the heart 6. Fetal deaths : 8 C. 1%
B. Diseases of the vascular system 7. Deaths under 28 days : 8 D. 100/1000 A. Dengue H.F
C. Pneumonias 8. Death due to rabies : 45 B. Malaria
D. Tuberculosis 9. Registered cases of rabies : 45 41. The following are all functions of the nurse in vital C. Contaminated Water Source
10. People with pneumonia : 79 statistics, which of the following is not? D. Tuberculosis
31. Alicia, a 9 year old child asked you “ What is the 11. People exposed with pneumonia : 2,593
common cause of death in my age group here in the 12. Total number of deaths from all causes : 10,998 A. Consolidate Data 48. All but one is a characteristic of a point source
Philippines? “ The nurse is correct if he will answer B. Collects Data epidemic, which one is not?
The following questions refer to these data C. Analyze Data
A. Pneumonia is the top leading cause of death in D. Tabulate Data A. The spread of the disease is caused by a common
children age 5 to 9 35. What is the crude birth rate of Barangay PinoyBSN? vehicle
B. Malignant neoplasm if common in your age group 42. The following are Notifiable diseases that needs to B. The disease is usually caused by contaminated food
C. Probability wise, You might die due to accidents A. 90/100,000 have a tally sheet in data reporting, Which one is not? C. There is a gradual increase of cases
D. Diseases of the respiratory system is the most B. 9/100 D. Epidemic is usually sudden
common cause of death in children C. 90/1000 A. Hypertension
D. 9/1000 B. Bronchiolitis 49. The only Microorganism monitored in cases of
32. In children 1 to 4 years old, which is the most C. Chemical Poisoning contaminated water is
common cause of death? 36. What is the cause specific death rate from D. Accidents
cardiovascular diseases? A. Vibrio Cholera
A. Diarrhea 43. Which of the following requires reporting within 24 B. Escherichia Coli
B. Accidents A. 27/100 hours? C. Entamoeba Histolytica
C. Pneumonia B. 1191/100,000 D. Coliform Test
D. Diseases of the heart C. 27/100,000 A. Neonatal tetanus
D. 1.1/1000 B. Measles 50. Dengue increase in number during June, July and
33. Working in the community as a PHN for almost 10 C. Hypertension August. This pattern is called
years, Aida knew the fluctuation in vital statistics. She 37. What is the Maternal Mortality rate of this D. Tetanus
knew that the most common cause of morbidity among barangay? A. Epidemic
the Filipinos is 44. Which Act declared that all communicable disease be B. Endemic
A. 6.55/1000 reported to the nearest health station? C. Cyclical
A. Diseases of the heart B. 5.89/1000 D. Secular
B. Diarrhea C. 1.36/1000 A. 1082
C. Pneumonia D. 3.67/1000 B. 1891 SITUATION : Field health services and information
D. Vascular system diseases C. 3573 system provides summary data on health service
38. What is the fetal death rate? D. 6675 delivery and selected program from the barangay level
34. Nurse Aida also knew that most maternal deaths are up to the national level. As a nurse, you should know the
caused by A. 3.49/1000 45. In the RHU Team, Which professional is directly process on how these information became processed
B. 10.04/1000 responsible in caring a sick person who is homebound? and consolidated.
A. Hemorrhage C. 3.14/1000
B. Other Complications related to pregnancy occurring D. 3.14/100,000 A. Midwife 51. All of the following are objectives of FHSIS Except
in the course of labor, delivery and puerperium B. Nurse
C. Hypertension complicating pregnancy, childbirth and 39. What is the attack rate of pneumonia? C. BHW A. To complete the clinical picture of chronic disease
puerperium D. Physician and describe their natural history
D. Abortion A. 3.04/1000 B. To provide standardized, facility level data base which
B. 7.18/1000 46. During epidemics, which of the following can be accessed for more in depth studies
SITUATION : Barangay PinoyBSN has the following data C. 32.82/100 epidemiological function will you have to perform first? C. To minimize recording and reporting burden allowing
in year 2006 D. 3.04/100 more time for patient care and promotive activities
A. Teaching the community on disease prevention D. To ensure that data reported are useful and accurate
1. July 1 population : 254,316 40. Determine the Case fatality ratio of rabies in this B. Assessment on suspected cases and are disseminated in a timely and easy to use fashion
2. Livebirths : 2,289 Barangay C. Monitor the condition of people affected
3. Deaths from maternal cause : 15 D. Determining the source and nature of the epidemic 52. What is the fundamental block or foundation of the
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field health service information system? A. Leprosy cases C. Provincial health office
B. TB cases D. Regional health office 70. Data submitted to the PHO is processed using what
A. Family treatment record C. Prenatal care type of technology?
B. Target Client list D. Diarrhea cases 65. Mang Raul entered the health center complaining of
C. Reporting forms fatigue and frequent syncope. You assessed Mang Raul A. Internet
D. Output record 59. This is the only mechanism through which data are and found out that he is severely malnourished and B. Microcomputer
routinely transmitted from once facility to another anemic. What record should you get first to document C. Supercomputer
53. What is the primary advantage of having a target these findings? D. Server Interlink Connections
client list? A. Family treatment record
B. Target Client list A. Family treatment record SITUATION : Community organizing is a process by which
A. Nurses need not to go back to FTR to monitor C. Reporting forms B. Target Client list people, health services and agencies of the community
treatment and services to beneficiaries thus saving time D. Output record C. Reporting forms are brought together to act and solve their own
and effort D. Output record problems.
B. Help monitor service rendered to clients in general 60. FHSIS/Q-3 Or the report for environmental health
C. Facilitate monitoring and supervision of services activities is prepared how frequently? 66. The information about Mang Raul’s address, full 71. Mang Ambo approaches you for counseling. You are
D. Facilitates easier reporting name, age, symptoms and diagnosis is recorded in an effective counselor if you
A. Daily
54. Which of the following is used to monitor particular B. Weekly A. Family treatment record A. Give good advice to Mang Ambo
groups that are qualified as eligible to a certain program C. Quarterly B. Target Client list B. Identify Mang Ambo’s problems
of the DOH? D. Yearly C. Reporting forms C. Convince Mang Ambo to follow your advice
D. Output record D. Help Mang Ambo identify his problems
A. Family treatment record 61. Nurse Budek is preparing the reporting form for
B. Target Client list weekly notifiable diseases. He knew that he will code the 67. Another entry is to be made for Mang Raul because 72. As a newly appointed PHN instructed to organize
C. Reporting forms report form as he is in the target client’s list, In what TCL should Mang Barangay Baritan, Which of the following is your initial
D. Output record Raul’s entry be documented? step in organizing the community for initial action?
A. FHSIS/E-1
55. In using the tally sheet, what is the recommended B. FHSIS/E-2 A. TCL Eligible Population A. Study the Barangay Health statistics and records
frequency in tallying activities and services? C. FHSIS/E-3 B. TCL Family Planning B. Make a courtesy call to the Barangay Captain
D. FHSIS/M-1 C. TCL Nutrition C. Meet with the Barangay Captain to make plans
A. Daily D. TCL Pre Natal D. Make a courtesy call to the Municipal Mayor
B. Weekly 62. In preparing the maternal death report, which of the
C. Monthly following correctly codes this occurrence? 68. The nurse uses the FHSIS Record system incorrectly 73. Preparatory phase is the first phase in organizing the
D. Quarterly when she found out that community. Which of the following is the initial step in
A. FHSIS/E-1 the preparatory phase?
56. When is the counting of the tally sheet done? B. FHSIS/E-2 A. She go to the individual or FTR for entry confirmation
C. FHSIS/E-3 in the Tally/Report Summary A. Area selection
A. At the end of the day D. FHSIS/M-1 B. She refer to other sources for completing monthly B. Community profiling
B. At the end of the week and quarterly reports C. Entry in the community
C. At the end of the month 63. Where should Nurse Budek bring the reporting forms C. She records diarrhea in the Tally sheet/Report form D. Integration with the people
D. At the end of the year if he is in the BHU Facility? with a code FHSIS/M-1
D. She records a Child who have frequent diarrhea in TCL 74. the most important factor in determining the proper
57. Target client list will be transmitted to the next A. Rural health office : Under Five area for community organizing is that this area should
facility in the form of B. FHSIS Main office
C. Provincial health office 69. The BHS Is the lowest level of reporting unit in FHSIS. A. Be already adopted by another organization
A. Family treatment record D. Regional health office A BHS can be considered a reporting unit if all of the B. Be able to finance the projects
B. Target Client list following are met except C. Have problems and needs assistance
C. Reporting forms 64. After bringing the reporting forms in the right facility D. Have people with expertise to be developed as
D. Output record for processing, Nurse Budek knew that the output A. It renders service to 3 barangays leaders
reports are solely produced by what office? B. There is a midwife the regularly renders service to the
58. All but one of the following are eligible target client area 75. Which of the following dwelling place should the
list A. Rural health office C. The BHS Have no mother BHS Nurse choose when integrating with the people?
B. FHSIS Main office D. It should be a satellite BHS
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A. A simple house in the border of Barangay Baritan and Nurse must first vegetables and fruits. He specified that the objective is community health problems and needs.
San Pablo to save money in buying vegetables and fruits that tend
B. A simple house with fencing and gate located in the A. Make a lesson plan to have a fluctuating and cyclical price. Which step in A. Residing in the area of assignment
center of Barangay Baritan B. Set learning goals and objective Community organizing process did he utilized? B. Listing down the name of person to contact for
C. A modest dwelling place where people will not C. Assess their learning needs courtesy call
hesitate to enter D. Review materials needed for training A. Fact finding C. Gathering initial information about the community
D. A modest dwelling place where people will not B. Determination of needs D. Preparing Agenda for the first meeting
hesitate to enter located in the center of the 81. Nurse Budek wrote a letter to PCSO asking them for C. Program formation
community assistance in their feeding programs for the community’s D. Education and Interpretation SITUATION : Health education is the process whereby
nutrition and health projects. PCSO then approved the knowledge, attitude and practice of people are changed
76. In choosing a leader in the community during the request and gave Budek 50,000 Pesos and a truckload of 86. One of the critical steps in COPAR is becoming one to improve individual, family and community health.
Organizational phase, Which among these people will rice, fruits and vegetables. Which phase of COPAR did with the people and understanding their culture and
you choose? Budek utilized? lifestyle. Which critical step in COPAR will the Nurse try 91. Which of the following is the correct sequence in
to immerse himself in the community? health education?
A. Miguel Zobel, 50 years old, Rich and Famous A. Preparatory
B. Rustom, 27 years old, Actor B. Organizational A. Integration 1. Information
C. Mang Ambo, 70, Willing to work for the desired C. Education and Training B. Social Mobilization 2. Communication
change D. Intersectoral Collaboration C. Ground Work 3. Education
D. Ricky, 30 years old, Influential and Willing to work E. Phase out D. Mobilization
for the desired change A. 1,2,3
82. Ideally, How many years should the Nurse stay in the 87. The Actual exercise of people power occurs during B. 3,2,1
77. Which type of leadership style should the leaders of community before he can phase out and be assured of a when? C. 1,3,2
the community practice? Self Reliant community? D. 3,1,2
A. Integration
A. Autocratic A. 5 years B. Social Mobilization 92. The health status of the people is greatly affected
B. Democratic B. 10 years C. Ground Work and determined by which of the following?
C. Laissez Faire C. 1 year D. Mobilization
D. Consultative D. 6 months A. Behavioral factors
88. Which steps in COPAR trains indigenous and informal B. Socioeconomic factors
78. Setting up Committee on Education and Training is in 83. Major discussion in community organization are leaders? C. Political factors
what phase of COPAR? made by D. Psychological factors
A. Ground Work
A. Preparatory A. The nurse B. Mobilization 93. Nurse Budek is conducting a health teaching to
B. Organizational B. The leaders of each committee C. Core Group formation Agnesia, 50 year old breast cancer survivor needing
C. Education and Training C. The entire group D. Integration rehabilitative measures. He knows that health education
D. Intersectoral Collaboration D. Collaborating Agencies is effective when
E. Phase out 89. As a PHN, One of your role is to organize the
84. The nurse should know that Organizational plan best community. Nurse Budek knows that the purposes of A. Agnesia recites the procedure and instructions
79. Community diagnosis is done to come up with a succeeds when community organizing are perfectly
profile of local health situation that will serve as basis of B. Agnesia’s behavior and outlook in life was changed
health programs and services. This is done in what phase 1. People sees its values 1. Move the community to act on their own problems positively
of COPAR? 2. People think its antagonistic professionally 2. Make people aware of their own problems C. Agnesia gave feedback to Budek saying that she
3. It is incompatible with their personal beliefs 3. Enable the nurse to solve the community problems understood the instruction
A. Preparatory 4. It is compatible with their personal beliefs 4. Offer people means of solving their own problems D. Agnesia requested a written instruction from Budek
B. Organizational
C. Education and Training A. 1 and 3 A. 1,2,3 94. Which of the following is true about health
D. Intersectoral Collaboration B. 2 and 4 B. 1,2,3,4 education?
E. Phase out C. 1 and 2 C. 1,2
D. 1 and 4 D. 1,2,4 A. It helps people attain their health through the nurse’s
80. The people named the community health workers sole efforts
based on the collective decision in accordance with the 85. Nurse Budek made a proposal that people should 90. This is considered the first act of integrating with the B. It should not be flexible
set criteria. Before they can be trained by the Nurse, The turn their backyard into small farming lots to plant people. This gives an in depth participation in C. It is a fast and mushroom like process
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D. It is a slow and continuous process D. Muscle Built COMMUNITY HEALTH NURSING Part 2
4. R.A. 1054 is also known as the Occupational Health
95. Which of the following factors least influence the 100. Appearance and disposition of clients are best 1. Which is the primary goal of community health Act. Aside from number of employees, what other factor
learning readiness of an adult learner? observed initially during which of the following nursing? must be considered in determining the occupational
situation? A. To support and supplement the efforts of the medical health privileges to which the workers will be entitled?
A. The individuals stage of development profession in the promotion of health and prevention of A. Type of occupation: agricultural, commercial,
B. Ability to concentrate on information to be learned A. Taking V/S illness industrial
C. The individual’s psychosocial adaptation to his illness B. Interview B. To enhance the capacity of individuals, families and B. Location of the workplace in relation to health
D. The internal impulses that drive the person to take C. Implementation of the initial care communities to cope with their health needs facilities
action D. Actual Physical examination C. To increase the productivity of the people by C. Classification of the business enterprise based on net
providing them with services that will increase their level profit
96. Which of the following is the most important of health D. Sex and age composition of employees
condition for diabetic patients to learn how to control D. To contribute to national development through
their diet? promotion of family welfare, focusing particularly on Answer: (B) Location of the workplace in relation to
mothers and children. health facilities
A. Use of pamphlets and other materials during Based on R.A. 1054, an occupational nurse must be
instructions Answer: (B) To enhance the capacity of individuals, employed when there are 30 to 100 employees and the
B. Motivation to be symptom free families and communities to cope with their health workplace is more than 1 km. away from the nearest
C. Ability of the patient to understand teaching needs health center.
instruction To contribute to national development through
D. Language used by the nurse promotion of family welfare, focusing particularly on 5. A business firm must employ an occupational health
mothers and children. nurse when it has at least how many employees?
97. An important skill that a primigravida has to acquire A. 21
is the ability to bathe her newborn baby and clean her 2. CHN is a community-based practice. Which best B. 101
breast if she decides to breastfeed her baby, Which of explains this statement? C. 201
the following learning domain will you classify the above A. The service is provided in the natural environment of D. 301
goals? people.
B. The nurse has to conduct community diagnosis to Answer: (B) 101
A. Psychomotor determine nursing needs and problems. Again, this is based on R.A. 1054.
B. Cognitive C. The services are based on the available resources
C. Affective within the community. 6. When the occupational health nurse employs
D. Attitudinal D. Priority setting is based on the magnitude of the ergonomic principles, she is performing which of her
health problems identified. roles?
98. When you prepare your teaching plan for a group of A. Health care provider
hypertensive patients, you first formulate your learning Answer: A. The service is provided in the natural B. Health educator
objectives. Which of the following steps in the nursing environment of people. C. Health care coordinator
process corresponds to the writing of the learning Community-based practice means providing care to D. Environmental manager
objectives? people in their own natural environments: the home,
school and workplace, for example. Answer: (D) Environmental manager
A. Planning Ergonomics is improving efficiency of workers by
B. Implementing 3. Population-focused nursing practice requires which of improving the worker’s environment through
C. Evaluation the following processes? appropriately designed furniture, for example.
C. Assessment A. Community organizing
B. Nursing process 7. A garment factory does not have an occupational
99. Rose, 50 years old and newly diagnosed diabetic C. Community diagnosis nurse. Who shall provide the occupational health needs
patient must learn how to inject insulin. Which of the D. Epidemiologic process of the factory workers?
following physical attribute is not in anyway related to A. Occupational health nurse at the Provincial Health
her ability to administer insulin? Answer: (C) Community diagnosis Office
Population-focused nursing care means providing care B. Physician employed by the factory
A. Strength based on the greater need of the majority of the C. Public health nurse of the RHU of their municipality
B. Coordination population. The greater need is identified through D. Rural sanitary inspector of the RHU of their
C. Dexterity community diagnosis. municipality
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A. It involves providing home care to sick people who are 15. Which is true of primary facilities?
Answer: (C) Public health nurse of the RHU of their not confined in the hospital. A. They are usually government-run. 19. R.A. 7160 mandates devolution of basic services from
municipality B. Services are provided free of charge to people within B. Their services are provided on an out-patient basis. the national government to local government units.
You’re right! This question is based on R.A.1054. the catchment area. C. They are training facilities for health professionals. Which of the following is the major goal of devolution?
C. The public health nurse functions as part of a team D. A community hospital is an example of this level of A. To strengthen local government units
8. “Public health services are given free of charge.” Is this providing a public health nursing services. health facilities. B. To allow greater autonomy to local government units
statement true or false? D. Public health nursing focuses on preventive, not C. To empower the people and promote their self-
A. The statement is true; it is the responsibility of curative, services. Answer: (B) Their services are provided on an out- reliance
government to provide basic services. patient basis. D. To make basic services more accessible to the people
B. The statement is false; people pay indirectly for public Answer: (D) Public health nursing focuses on Primary facilities government and non-government
health services. preventive, not curative, services. facilities that provide basic out-patient services. Answer: (C) To empower the people and promote their
C. The statement may be true or false, depending on the The catchment area in PHN consists of a residential self-reliance
specific service required. community, many of whom are well individuals who 16. Which is an example of the school nurse’s health People empowerment is the basic motivation behind
D. The statement may be true or false, depending on have greater need for preventive rather than curative care provider functions? devolution of basic services to LGU’s.
policies of the government concerned. services. A. Requesting for BCG from the RHU for school entrant
immunization 20. Who is the Chairman of the Municipal Health Board?
Answer: (B) The statement is false; people pay 12. According to Margaret Shetland, the philosophy of B. Conducting random classroom inspection during a A. Mayor
indirectly for public health services. public health nursing is based on which of the following? measles epidemic B. Municipal Health Officer
Community health services, including public health A. Health and longevity as birthrights C. Taking remedial action on an accident hazard in the C. Public Health Nurse
services, are pre-paid services, though taxation, for B. The mandate of the state to protect the birthrights of school playground D. Any qualified physician
example. its citizens D. Observing places in the school where pupils spend
C. Public health nursing as a specialized field of nursing their free time Answer: (A) Mayor
9. According to C.E.Winslow, which of the following is D. The worth and dignity of man The local executive serves as the chairman of the
the goal of Public Health? Answer: (B) Conducting random classroom inspection Municipal Health Board.
A. For people to attain their birthrights of health and Answer: (D) The worth and dignity of man during a measles epidemic
longevity This is a direct quote from Dr. Margaret Shetland’s Random classroom inspection is assessment of 21. Which level of health facility is the usual point of
B. For promotion of health and prevention of disease statements on Public Health Nursing. pupils/students and teachers for signs of a health entry of a client into the health care delivery system?
C. For people to have access to basic health services problem prevalent in the community. A. Primary
D. For people to be organized in their health efforts 13. Which of the following is the mission of the B. Secondary
Department of Health? 17. When the nurse determines whether resources were C. Intermediate
Answer: (A) For people to attain their birthrights of A. Health for all Filipinos maximized in implementing Ligtas Tigdas, she is D. Tertiary
health and longevity B. Ensure the accessibility and quality of health care evaluating
According to Winslow, all public health efforts are for C. Improve the general health status of the population A. Effectiveness Answer: (A) Primary
people to realize their birthrights of health and D. Health in the hands of the Filipino people by the year B. Efficiency The entry of a person into the health care delivery
longevity. 2020 C. Adequacy system is usually through a consultation in out-patient
D. Appropriateness services.
10. We say that a Filipino has attained longevity when he Answer: (B) Ensure the accessibility and quality of
is able to reach the average lifespan of Filipinos. What health care Answer: (B) Efficiency 22. The public health nurse is the supervisor of rural
other statistic may be used to determine attainment of (none) Efficiency is determining whether the goals were health midwives. Which of the following is a supervisory
longevity? attained at the least possible cost. function of the public health nurse?
A. Age-specific mortality rate 14. Region IV Hospital is classified as what level of A. Referring cases or patients to the midwife
B. Proportionate mortality rate facility? 18. You are a new B.S.N. graduate. You want to become B. Providing technical guidance to the midwife
C. Swaroop’s index A. Primary a Public Health Nurse. Where will you apply? C. Providing nursing care to cases referred by the
D. Case fatality rate B. Secondary A. Department of Health midwife
C. Intermediate B. Provincial Health Office D. Formulating and implementing training programs for
Answer: (C) Swaroop’s index D. Tertiary C. Regional Health Office midwives
Swaroop’s index is the percentage of the deaths aged 50 D. Rural Health Unit
years or older. Its inverse represents the percentage of Answer: (D) Tertiary Answer: (B) Providing technical guidance to the
untimely deaths (those who died younger than 50 years). Regional hospitals are tertiary facilities because they Answer: (D) Rural Health Unit midwife
serve as training hospitals for the region. R.A. 7160 devolved basic health services to local The nurse provides technical guidance to the midwife in
11. Which of the following is the most prominent feature government units (LGU’s ). The public health nurse is an the care of clients, particularly in the implementation of
of public health nursing? employee of the LGU.
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management guidelines, as in Integrated Management Diseases, enacted in 1929, mandated the reporting of 30. Which step in community organizing involves training problem
of Childhood Illness. diseases listed in the law to the nearest health station. of potential leaders in the community? D. Identify the health problem as a common concern
A. Integration
23. One of the participants in a hilot training class asked 27. According to Freeman and Heinrich, community B. Community organization Answer: (A) Participate in community activities for the
you to whom she should refer a patient in labor who health nursing is a developmental service. Which of the C. Community study solution of a community problem
develops a complication. You will answer, to the following best illustrates this statement? D. Core group formation Participation in community activities in resolving a
A. Public Health Nurse A. The community health nurse continuously develops community problem may be in any of the processes
B. Rural Health Midwife himself personally and professionally. Answer: (D) Core group formation mentioned in the other choices.
C. Municipal Health Officer B. Health education and community organizing are In core group formation, the nurse is able to transfer the
D. Any of these health professionals necessary in providing community health services. technology of community organizing to the potential or 34. Tertiary prevention is needed in which stage of the
C. Community health nursing is intended primarily for informal community leaders through a training program. natural history of disease?
Answer: (C) Municipal Health Officer health promotion and prevention and treatment of A. Pre-pathogenesis
A public health nurse and rural health midwife can disease. 31. In which step are plans formulated for solving B. Pathogenesis
provide care during normal childbirth. A physician should D. The goal of community health nursing is to provide community problems? C. Prodromal
attend to a woman with a complication during labor. nursing services to people in their own places of A. Mobilization D. Terminal
residence. B. Community organization
24. You are the public health nurse in a municipality with C. Follow-up/extension Answer: (D) Terminal
a total population of about 20,000. There are 3 rural Answer: (B) Health education and community D. Core group formation Tertiary prevention involves rehabilitation, prevention of
health midwives among the RHU personnel. How many organizing are necessary in providing community health permanent disability and disability limitation appropriate
more midwife items will the RHU need? services. Answer: (B) Community organization for convalescents, the disabled, complicated cases and
A. 1 The community health nurse develops the health Community organization is the step when community the terminally ill (those in the terminal stage of a
B. 2 capability of people through health education and assemblies take place. During the community assembly, disease)
C. 3 community organizing activities. the people may opt to formalize the community
D. The RHU does not need any more midwife item. organization and make plans for community action to 35. Isolation of a child with measles belongs to what
28. Which disease was declared through Presidential resolve a community health problem. level of prevention?
Answer: (A) 1 Proclamation No. 4 as a target for eradication in the A. Primary
Each rural health midwife is given a population Philippines? 32. The public health nurse takes an active role in B. Secondary
assignment of about 5,000. A. Poliomyelitis community participation. What is the primary goal of C. Intermediate
B. Measles community organizing? D. Tertiary
25. If the RHU needs additional midwife items, you will C. Rabies A. To educate the people regarding community health
submit the request for additional midwife items for D. Neonatal tetanus problems Answer: (A) Primary
approval to the B. To mobilize the people to resolve community health The purpose of isolating a client with a communicable
A. Rural Health Unit Answer: (B) Measles problems disease is to protect those who are not sick (specific
B. District Health Office Presidential Proclamation No. 4 is on the Ligtas Tigdas C. To maximize the community’s resources in dealing disease prevention).
C. Provincial Health Office Program. with health problems
D. Municipal Health Board D. To maximize the community’s resources in dealing 36. On the other hand, Operation Timbang is _____
29. The public health nurse is responsible for presenting with health problems prevention.
Answer: (D) Municipal Health Board the municipal health statistics using graphs and tables. A. Primary
As mandated by R.A. 7160, basic health services have To compare the frequency of the leading causes of Answer: (D) To maximize the community’s resources in B. Secondary
been devolved from the national government to local mortality in the municipality, which graph will you dealing with health problems C. Intermediate
government units. prepare? Community organizing is a developmental service, with D. Tertiary
A. Line the goal of developing the people’s self-reliance in
26. As an epidemiologist, the nurse is responsible for B. Bar dealing with community health problems. A, B and C are Answer: (B) Secondary
reporting cases of notifiable diseases. What law C. Pie objectives of contributory objectives to this goal. Operation Timbang is done to identify members of the
mandates reporting of cases of notifiable diseases? D. Scatter diagram susceptible population who are malnourished. Its
A. Act 3573 33. An indicator of success in community organizing is purpose is early diagnosis and, subsequently, prompt
B. R.A. 3753 Answer: (B) Bar when people are able to treatment.
C. R.A. 1054 A bar graph is used to present comparison of values, a A. Participate in community activities for the solution of
D. R.A. 1082 line graph for trends over time or age, a pie graph for a community problem 37. Which type of family-nurse contact will provide you
population composition or distribution, and a scatter B. Implement activities for the solution of the with the best opportunity to observe family dynamics?
Answer: (A) Act 3573 diagram for correlation of two variables. community problem A. Clinic consultation
Act 3573, the Law on Reporting of Communicable C. Plan activities for the solution of the community B. Group conference
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C. Home visit 41. Which is CONTRARY to the principles in planning a 44. The public health nurse conducts a study on the 47. The primary purpose of conducting an epidemiologic
D. Written communication home visit? factors contributing to the high mortality rate due to investigation is to
A. A home visit should have a purpose or objective. heart disease in the municipality where she works. A. Delineate the etiology of the epidemic
Answer: (C) Home visit B. The plan should revolve around family health needs. Which branch of epidemiology does the nurse practice in B. Encourage cooperation and support of the community
Dynamics of family relationships can best be observed in C. A home visit should be conducted in the manner this situation? C. Identify groups who are at risk of contracting the
the family’s natural environment, which is the home. prescribed by the RHU. A. Descriptive disease
D. Planning of continuing care should involve a B. Analytical D. Identify geographical location of cases of the disease
38. The typology of family nursing problems is used in responsible family member. C. Therapeutic in the community
the statement of nursing diagnosis in the care of D. Evaluation
families. The youngest child of the de los Reyes family Answer: (C) A home visit should be conducted in the Answer: (A) Delineate the etiology of the epidemic
has been diagnosed as mentally retarded. This is manner prescribed by the RHU. Answer: (B) Analytical Delineating the etiology of an epidemic is identifying its
classified as a The home visit plan should be flexible and practical, Analytical epidemiology is the study of factors or source.
A. Health threat depending on factors, such as the family’s needs and the determinants affecting the patterns of occurrence and
B. Health deficit resources available to the nurse and the family. distribution of disease in a community. 48. Which is a characteristic of person-to-person
C. Foreseeable crisis propagated epidemics?
D. Stress point 42. The PHN bag is an important tool in providing 45. Which of the following is a function of epidemiology? A. There are more cases of the disease than expected.
nursing care during a home visit. The most important A. Identifying the disease condition based on B. The disease must necessarily be transmitted through a
Answer: (B) Health deficit principle of bag technique states that it manifestations presented by a client vector.
Failure of a family member to develop according to what A. Should save time and effort. B. Determining factors that contributed to the C. The spread of the disease can be attributed to a
is expected, as in mental retardation, is a health deficit. B. Should minimize if not totally prevent the spread of occurrence of pneumonia in a 3 year old common vehicle.
infection. C. Determining the efficacy of the antibiotic used in the D. There is a gradual build up of cases before the
39. The de los Reyes couple have a 6-year old child C. Should not overshadow concern for the patient and treatment of the 3 year old client with pneumonia epidemic becomes easily noticeable.
entering school for the first time. The de los Reyes family his family. D. Evaluating the effectiveness of the implementation of
has a D. May be done in a variety of ways depending on the the Integrated Management of Childhood Illness Answer: (D) There is a gradual build up of cases before
A. Health threat home situation, etc. the epidemic becomes easily noticeable.
B. Health deficit Answer: (D) Evaluating the effectiveness of the A gradual or insidious onset of the epidemic is usually
C. Foreseeable crisis Answer: (B) Should minimize if not totally prevent the implementation of the Integrated Management of observable in person-to-person propagated epidemics.
D. Stress point spread of infection. Childhood Illness
Bag technique is performed before and after handling a Epidemiology is used in the assessment of a community 49. In the investigation of an epidemic, you compare the
Answer: (C) Foreseeable crisis client in the home to prevent transmission of infection or evaluation of interventions in community health present frequency of the disease with the usual
Entry of the 6-year old into school is an anticipated to and from the client. practice. frequency at this time of the year in this community. This
period of unusual demand on the family. is done during which stage of the investigation?
43. To maintain the cleanliness of the bag and its 46. Which of the following is an epidemiologic function A. Establishing the epidemic
40. Which of the following is an advantage of a home contents, which of the following must the nurse do? of the nurse during an epidemic? B. Testing the hypothesis
visit? A. Wash his/her hands before and after providing A. Conducting assessment of suspected cases to detect C. Formulation of the hypothesis
A. It allows the nurse to provide nursing care to a greater nursing care to the family members. the communicable disease D. Appraisal of facts
number of people. B. In the care of family members, as much as possible, B. Monitoring the condition of the cases affected by the
B. It provides an opportunity to do first hand appraisal of use only articles taken from the bag. communicable disease Answer: (A) Establishing the epidemic
the home situation. C. Put on an apron to protect her uniform and fold it C. Participating in the investigation to determine the Establishing the epidemic is determining whether there
C. It allows sharing of experiences among people with with the right side out before putting it back into the source of the epidemic is an epidemic or not. This is done by comparing the
similar health problems. bag. D. Teaching the community on preventive measures present number of cases with the usual number of cases
D. It develops the family’s initiative in providing for D. At the end of the visit, fold the lining on which the bag against the disease of the disease at the same time of the year, as well as
health needs of its members. was placed, ensuring that the contaminated side is on establishing the relatedness of the cases of the disease.
the outside. Answer: (C) Participating in the investigation to
Answer: (B) It provides an opportunity to do first hand determine the source of the epidemic 50. The number of cases of Dengue fever usually
appraisal of the home situation. Answer: (A) Wash his/her hands before and after Epidemiology is the study of patterns of occurrence and increases towards the end of the rainy season. This
Choice A is not correct since a home visit requires that providing nursing care to the family members. distribution of disease in the community, as well as the pattern of occurrence of Dengue fever is best described
the nurse spend so much time with the family. Choice C Choice B goes against the idea of utilizing the family’s factors that affect disease patterns. The purpose of an as
is an advantage of a group conference, while choice D is resources, which is encouraged in CHN. Choices C and D epidemiologic investigation is to identify the source of A. Epidemic occurrence
true of a clinic consultation. goes against the principle of asepsis of confining the an epidemic, i.e., what brought about the epidemic. B. Cyclical variation
contaminated surface of objects. C. Sporadic occurrence
D. Secular variation
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diagnostic examination? C. Population pyramid

Answer: (B) Cyclical variation A. Effectiveness Answer: (B) Letter of Instruction No. 949 D. Any of these may be used.
A cyclical variation is a periodic fluctuation in the B. Efficacy Letter of Instruction 949 was issued by then President
number of cases of a disease in the community. C. Specificity Ferdinand Marcos, directing the formerly called Ministry Answer: (D) Any of these may be used.
D. Sensitivity of Health, now the Department of Health, to utilize Sex ratio and sex proportion are used to determine the
51. In the year 1980, the World Health Organization Primary Health Care approach in planning and sex composition of a population. A population pyramid is
declared the Philippines, together with some other Answer: (D) Sensitivity implementing health programs. used to present the composition of a population by age
countries in the Western Pacific Region, “free” of which Sensitivity is the capacity of a diagnostic examination to and sex.
disease? detect cases of the disease. If a test is 100% sensitive, all 59. Which of the following demonstrates intersectoral
A. Pneumonic plague the cases tested will have a positive result, i.e., there will linkages? 63. Which of the following is a natality rate?
B. Poliomyelitis be no false negative results. A. Two-way referral system A. Crude birth rate
C. Small pox B. Team approach B. Neonatal mortality rate
D. Anthrax 55. Use of appropriate technology requires knowledge of C. Endorsement done by a midwife to another midwife C. Infant mortality rate
indigenous technology. Which medicinal herb is given for D. Cooperation between the PHN and public school D. General fertility rate
Answer: (C) Small pox fever, headache and cough? teacher
The last documented case of Small pox was in 1977 at A. Sambong Answer: (A) Crude birth rate
Somalia. B. Tsaang gubat Answer: (D) Cooperation between the PHN and public Natality means birth. A natality rate is a birth rate.
C. Akapulko school teacher
52. In the census of the Philippines in 1995, there were D. Lagundi Intersectoral linkages refer to working relationships 64. You are computing the crude death rate of your
about 35,299,000 males and about 34,968,000 females. between the health sector and other sectors involved in municipality, with a total population of about 18,000, for
What is the sex ratio? Answer: (D) Lagundi community development. last year. There were 94 deaths. Among those who died,
A. 99.06:100 Sambong is used as a diuretic. Tsaang gubat is used to 20 died because of diseases of the heart and 32 were
B. 100.94:100 relieve diarrhea. Akapulko is used for its antifungal 60. The municipality assigned to you has a population of aged 50 years or older. What is the crude death rate?
C. 50.23% property. about 20,000. Estimate the number of 1-4 year old A. 4.2/1,000
D. 49.76% children who will be given Retinol capsule 200,000 I.U. B. 5.2/1,000
56. What law created the Philippine Institute of every 6 months. C. 6.3/1,000
Answer: (B) 100.94:100 Traditional and Alternative Health Care? A. 1,500 D. 7.3/1,000
Sex ratio is the number of males for every 100 females in A. R.A. 8423 B. 1,800
the population. B. R.A. 4823 C. 2,000 Answer: (B) 5.2/1,000
C. R.A. 2483 D. 2,300 To compute crude death rate divide total number of
53. Primary health care is a total approach to community D. R.A. 3482 deaths (94) by total population (18,000) and multiply by
development. Which of the following is an indicator of Answer: (D) 2,300 1,000.
success in the use of the primary health care approach? Answer: (A) R.A. 8423 Based on the Philippine population composition, to
A. Health services are provided free of charge to (none) estimate the number of 1-4 year old children, multiply 65. Knowing that malnutrition is a frequent community
individuals and families. total population by 11.5%. health problem, you decided to conduct nutritional
B. Local officials are empowered as the major decision 57. In traditional Chinese medicine, the yielding, assessment. What population is particularly susceptible
makers in matters of health. negative and feminine force is termed 61. Estimate the number of pregnant women who will be to protein energy malnutrition (PEM)?
C. Health workers are able to provide care based on A. Yin given tetanus toxoid during an immunization outreach A. Pregnant women and the elderly
identified health needs of the people. B. Yang activity in a barangay with a population of about 1,500. B. Under-5 year old children
D. Health programs are sustained according to the level C. Qi A. 265 C. 1-4 year old children
of development of the community. D. Chai B. 300 D. School age children
C. 375
Answer: (D) Health programs are sustained according to Answer: (A) Yin D. 400 Answer: (C) 1-4 year old children
the level of development of the community. Yang is the male dominating, positive and masculine Preschoolers are the most susceptible to PEM because
Primary health care is essential health care that can be force. Answer: (A) 265 they have generally been weaned. Also, this is the
sustained in all stages of development of the To estimate the number of pregnant women, multiply population who, unable to feed themselves, are often
community. 58. What is the legal basis for Primary Health Care the total population by 3.5%. the victims of poor intrafamilial food distribution.
approach in the Philippines?
54. Sputum examination is the major screening tool for A. Alma Ata Declaration on PHC 62. To describe the sex composition of the population, 66. Which statistic can give the most accurate reflection
pulmonary tuberculosis. Clients would sometimes get B. Letter of Instruction No. 949 which demographic tool may be used? of the health status of a community?
false negative results in this exam. This means that the C. Presidential Decree No. 147 A. Sex ratio A. 1-4 year old age-specific mortality rate
test is not perfect in terms of which characteristic of a D. Presidential Decree 996 B. Sex proportion B. Infant mortality rate
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C. Swaroop’s index 70. You will gather data for nutritional assessment of a and other relevant data, such as dates when clients centers able to comply with standards.
D. Crude death rate purok. You will gather information only from families collected their monthly supply of drugs. Sentrong Sigla Movement is a joint project of the DOH
with members who belong to the target population for and local government units. Its main strategy is
Answer: (C) Swaroop’s index PEM. What method of data gathering is best for this 74. Civil registries are important sources of data. Which certification of health centers that are able to comply
Swaroop’s index is the proportion of deaths aged 50 purpose? law requires registration of births within 30 days from with standards set by the DOH.
years and above. The higher the Swaroop’s index of a A. Census the occurrence of the birth?
population, the greater the proportion of the deaths B. Survey A. P.D. 651 78. Which of the following women should be considered
who were able to reach the age of at least 50 years, i.e., C. Record review B. Act 3573 as special targets for family planning?
more people grew old before they died. D. Review of civil registry C. R.A. 3753 A. Those who have two children or more
67. In the past year, Barangay A had an average D. R.A. 3375 B. Those with medical conditions such as anemia
population of 1655. 46 babies were born in that year, 2 Answer: (B) Survey C. Those younger than 20 years and older than 35 years
of whom died less than 4 weeks after they were born. A survey, also called sample survey, is data gathering Answer: (A) P.D. 651 D. Those who just had a delivery within the past 15
There were 4 recorded stillbirths. What is the neonatal about a sample of the population. P.D. 651 amended R.A. 3753, requiring the registry of months
mortality rate? births within 30 days from their occurrence.
A. 27.8/1,000 71. In the conduct of a census, the method of population Answer: (D) Those who just had a delivery within the
B. 43.5/1,000 assignment based on the actual physical location of the 75. Which of the following professionals can sign the past 15 months
C. 86.9/1,000 people is termed birth certificate? The ideal birth spacing is at least two years. 15 months
D. 130.4/1,000 A. De jure A. Public health nurse plus 9 months of pregnancy = 2 years.
B. De locus B. Rural health midwife
Answer: (B) 43.5/1,000 C. De facto C. Municipal health officer 79. Freedom of choice is one of the policies of the Family
To compute for neonatal mortality rate, divide the D. De novo D. Any of these health professionals Planning Program of the Philippines. Which of the
number of babies who died before reaching the age of following illustrates this principle?
28 days by the total number of live births, then multiply Answer: (C) De facto Answer: (D) Any of these health professionals A. Information dissemination about the need for family
by 1,000. The other method of population assignment, de jure, is D. R.A. 3753 states that any birth attendant may sign the planning
based on the usual place of residence of the people. certificate of live birth. B. Support of research and development in family
68. Which statistic best reflects the nutritional status of a planning methods
population? 72. The Field Health Services and Information System 76. Which criterion in priority setting of health problems C. Adequate information for couples regarding the
A. 1-4 year old age-specific mortality rate (FHSIS) is the recording and reporting system in public is used only in community health care? different methods
B. Proportionate mortality rate health care in the Philippines. The Monthly Field Health A. Modifiability of the problem D. Encouragement of couples to take family planning as
C. Infant mortality rate Service Activity Report is a form used in which of the B. Nature of the problem presented a joint responsibility
D. Swaroop’s index components of the FHSIS? C. Magnitude of the health problem
A. Tally report D. Preventive potential of the health problem Answer: (C) Adequate information for couples
Answer: (A) 1-4 year old age-specific mortality rate B. Output report regarding the different methods
Since preschoolers are the most susceptible to the C. Target/client list Answer: (C) Magnitude of the health problem To enable the couple to choose freely among different
effects of malnutrition, a population with poor D. Individual health record Magnitude of the problem refers to the percentage of methods of family planning, they must be given full
nutritional status will most likely have a high 1-4 year old the population affected by a health problem. The other information regarding the different methods that are
age-specific mortality rate, also known as child mortality Answer: (A) Tally report choices are criteria considered in both family and available to them, considering the availability of quality
rate. A tally report is prepared monthly or quarterly by the community health care. services that can support their choice.
RHU personnel and transmitted to the Provincial Health
69. What numerator is used in computing general Office. 77. The Sentrong Sigla Movement has been launched to 80. A woman, 6 months pregnant, came to the center for
fertility rate? improve health service delivery. Which of the following consultation. Which of the following substances is
A. Estimated midyear population 73. To monitor clients registered in long-term regimens, is/are true of this movement? contraindicated?
B. Number of registered live births such as the Multi-Drug Therapy, which component will A. This is a project spearheaded by local government A. Tetanus toxoid
C. Number of pregnancies in the year be most useful? units. B. Retinol 200,000 IU
D. Number of females of reproductive age A. Tally report B. It is a basis for increasing funding from local C. Ferrous sulfate 200 mg
B. Output report government units. D. Potassium iodate 200 mg. capsule
Answer: (B) Number of registered live births C. Target/client list C. It encourages health centers to focus on disease
To compute for general or total fertility rate, divide the D. Individual health record prevention and control. Answer: (B) Retinol 200,000 IU
number of registered live births by the number of D. Its main strategy is certification of health centers able Retinol 200,000 IU is a form of megadose Vitamin A. This
females of reproductive age (15-45 years), then multiply Answer: (C) Target/client list to comply with standards. may have a teratogenic effect.
by 1,000. The MDT Client List is a record of clients enrolled in MDT
Answer: (D) Its main strategy is certification of health
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81. During prenatal consultation, a client asked you if Answer: (D) Explain to her that putting the baby to 88. What is given to a woman within a month after the
she can have her delivery at home. After history taking breast will lessen blood loss after delivery. delivery of a baby? 92. Which immunization produces a permanent scar?
and physical examination, you advised her against a Suckling of the nipple stimulates the release of oxytocin A. Malunggay capsule A. DPT
home delivery. Which of the following findings by the posterior pituitary gland, which causes uterine B. Ferrous sulfate 100 mg. OD B. BCG
disqualifies her for a home delivery? contraction. Lactation begins 1 to 3 days after delivery. C. Retinol 200,000 I.U., 1 capsule C. Measles vaccination
A. Her OB score is G5P3. Nipple stretching exercises are done when the nipples D. Potassium iodate 200 mg, 1 capsule D. Hepatitis B vaccination
B. She has some palmar pallor. are flat or inverted. Frequent washing dries up the
C. Her blood pressure is 130/80. nipples, making them prone to the formation of fissures. Answer: (C) Retinol 200,000 I.U., 1 capsule Answer: (B) BCG
D. Her baby is in cephalic presentation. A capsule of Retinol 200,000 IU is given within 1 month BCG causes the formation of a superficial abscess, which
85. A primigravida is instructed to offer her breast to the after delivery. Potassium iodate is given during begins 2 weeks after immunization. The abscess heals
Answer: (A) Her OB score is G5P3. baby for the first time within 30 minutes after delivery. pregnancy; malunggay capsule is not routinely without treatment, with the formation of a permanent
Only women with less than 5 pregnancies are qualified What is the purpose of offering the breast this early? administered after delivery; and ferrous sulfate is taken scar.
for a home delivery. It is also advisable for a primigravida A. To initiate the occurrence of milk letdown for two months after delivery.
to have delivery at a childbirth facility. B. To stimulate milk production by the mammary acini 93. A 4-week old baby was brought to the health center
C. To make sure that the baby is able to get the 89. Which biological used in Expanded Program on for his first immunization. Which can be given to him?
82. Inadequate intake by the pregnant woman of which colostrum Immunization (EPI) is stored in the freezer? A. DPT1
vitamin may cause neural tube defects? D. To allow the woman to practice breastfeeding in the A. DPT B. OPV1
A. Niacin presence of the health worker B. Tetanus toxoid C. Infant BCG
B. Riboflavin C. Measles vaccine D. Hepatitis B vaccine 1
C. Folic acid Answer: (B) To stimulate milk production by the D. Hepatitis B vaccine
D. Thiamine mammary acini Answer: (C) Infant BCG
Suckling of the nipple stimulates prolactin reflex (the Answer: (C) Measles vaccine Infant BCG may be given at birth. All the other
Answer: (C) Folic acid release of prolactin by the anterior pituitary gland), Among the biologicals used in the Expanded Program on immunizations mentioned can be given at 6 weeks of
It is estimated that the incidence of neural tube defects which initiates lactation. Immunization, measles vaccine and OPV are highly age.
can be reduced drastically if pregnant women have an sensitive to heat, requiring storage in the freezer.
adequate intake of folic acid. 86. In a mothers’ class, you discuss proper breastfeeding 94. You will not give DPT 2 if the mother says that the
technique. Which is of these is a sign that the baby has 90. Unused BCG should be discarded how many hours infant had
83. You are in a client’s home to attend to a delivery. “latched on” to the breast properly? after reconstitution? A. Seizures a day after DPT 1.
Which of the following will you do first? A. The baby takes shallow, rapid sucks. A. 2 B. Fever for 3 days after DPT 1.
A. Set up the sterile area. B. The mother does not feel nipple pain. B. 4 C. Abscess formation after DPT 1.
B. Put on a clean gown or apron. C. The baby’s mouth is only partly open. C. 6 D. Local tenderness for 3 days after DPT 1.
C. Cleanse the client’s vulva with soap and water. D. Only the mother’s nipple is inside the baby’s mouth. D. At the end of the day
D. Note the interval, duration and intensity of labor Answer: (A) Seizures a day after DPT 1.
contractions. Answer: (B) The mother does not feel nipple pain. Answer: (B) 4 Seizures within 3 days after administration of DPT is an
When the baby has properly latched on to the breast, he While the unused portion of other biologicals in EPI may indication of hypersensitivity to pertussis vaccine, a
Answer: (D) Note the interval, duration and intensity of takes deep, slow sucks; his mouth is wide open; and be given until the end of the day, only BCG is discarded 4 component of DPT. This is considered a specific
labor contractions. much of the areola is inside his mouth. And, you’re right! hours after reconstitution. This is why BCG immunization contraindication to subsequent doses of DPT.
Assessment of the woman should be done first to The mother does not feel nipple pain. is scheduled only in the morning.
determine whether she is having true labor and, if so, 95. A 2-month old infant was brought to the health
what stage of labor she is in. 87. You explain to a breastfeeding mother that breast 91. In immunizing school entrants with BCG, you are not center for immunization. During assessment, the infant’s
milk is sufficient for all of the baby’s nutrient needs only obliged to secure parental consent. This is because of temperature registered at 38.1°C. Which is the best
84. In preparing a primigravida for breastfeeding, which up to ____. which legal document? course of action that you will take?
of the following will you do? A. 3 months A. P.D. 996 A. Go on with the infant’s immunizations.
A. Tell her that lactation begins within a day after B. 6 months B. R.A. 7846 B. Give Paracetamol and wait for his fever to subside.
delivery. C. 1 year C. Presidential Proclamation No. 6 C. Refer the infant to the physician for further
B. Teach her nipple stretching exercises if her nipples are D. 2 years D. Presidential Proclamation No. 46 assessment.
everted. D. Advise the infant’s mother to bring him back for
C. Instruct her to wash her nipples before and after each Answer: (B) 6 months Answer: (A) P.D. 996 immunization when he is well.
breastfeeding. After 6 months, the baby’s nutrient needs, especially the Presidential Decree 996, enacted in 1976, made
D. Explain to her that putting the baby to breast will baby’s iron requirement, can no longer be provided by immunization in the EPI compulsory for children under 8 Answer: (A) Go on with the infant’s immunizations.
lessen blood loss after delivery. mother’s milk alone. years of age. Hepatitis B vaccination was made In the EPI, fever up to 38.5°C is not a contraindication to
compulsory for the same age group by R.A. 7846. immunization. Mild acute respiratory tract infection,
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simple diarrhea and malnutrition are not Answers A, C and D are done for a client classified as Oresol more slowly. which is not observable during physical examination.The
contraindications either. having pneumonia. earliest visible lesion is conjunctival xerosis or dullness of
Answer: (D) Let the child rest for 10 minutes then the conjunctiva due to inadequate tear production.
96. A pregnant woman had just received her 4th dose of 100. A 5-month old infant was brought by his mother to continue giving Oresol more slowly.
tetanus toxoid. Subsequently, her baby will have the health center because of diarrhea occurring 4 to 5 If the child vomits persistently, that is, he vomits 106. To prevent xerophthalmia, young children are given
protection against tetanus for how long? times a day. His skin goes back slowly after a skin pinch everything that he takes in, he has to be referred Retinol capsule every 6 months. What is the dose given
A. 1 year and his eyes are sunken. Using the IMCI guidelines, you urgently to a hospital. Otherwise, vomiting is managed to preschoolers?
B. 3 years will classify this infant in which category? by letting the child rest for 10 minutes and then A. 10,000 IU
C. 10 years A. No signs of dehydration continuing with Oresol administration. Teach the mother B. 20,000 IU
D. Lifetime B. Some dehydration to give Oresol more slowly. C. 100,000 IU
C. Severe dehydration D. 200,000 IU
Answer: (A) 1 year D. The data is insufficient. 103. A 1 ½ year old child was classified as having 3rd
The baby will have passive natural immunity by placental degree protein energy malnutrition, kwashiorkor. Which Answer: (D) 200,000 IU
transfer of antibodies. The mother will have active Answer: (B) Some dehydration of the following signs will be most apparent in this child? Preschoolers are given Retinol 200,000 IU every 6
artificial immunity lasting for about 10 years. 5 doses will Using the assessment guidelines of IMCI, a child (2 A. Voracious appetite months. 100,000 IU is given once to infants aged 6 to 12
give the mother lifetime protection. months to 5 years old) with diarrhea is classified as B. Wasting months. The dose for pregnant women is 10,000 IU.
having SOME DEHYDRATION if he shows 2 or more of C. Apathy
97. A 4-month old infant was brought to the health the following signs: restless or irritable, sunken eyes, the D. Edema 107. The major sign of iron deficiency anemia is pallor.
center because of cough. Her respiratory rate is skin goes back slow after a skin pinch. What part is best examined for pallor?
42/minute. Using the Integrated Management of Child Answer: (D) Edema A. Palms
Illness (IMCI) guidelines of assessment, her breathing is 101. Based on assessment, you classified a 3-month old Edema, a major sign of kwashiorkor, is caused by B. Nailbeds
considered infant with the chief complaint of diarrhea in the decreased colloidal osmotic pressure of the blood C. Around the lips
A. Fast category of SOME DEHYDRATION. Based on IMCI brought about by hypoalbuminemia. Decreased blood D. Lower conjunctival sac
B. Slow management guidelines, which of the following will you albumin level is due a protein-deficient diet.
C. Normal do? Answer: (A) Palms
D. Insignificant A. Bring the infant to the nearest facility where IV fluids 104. Assessment of a 2-year old child revealed “baggy The anatomic characteristics of the palms allow a
can be given. pants”. Using the IMCI guidelines, how will you manage reliable and convenient basis for examination for pallor.
Answer: (C) Normal B. Supervise the mother in giving 200 to 400 ml. of this child? 108. Food fortification is one of the strategies to prevent
In IMCI, a respiratory rate of 50/minute or more is fast Oresol in 4 hours. A. Refer the child urgently to a hospital for confinement. micronutrient deficiency conditions. R.A. 8976 mandates
breathing for an infant aged 2 to 12 months. C. Give the infant’s mother instructions on home B. Coordinate with the social worker to enroll the child in fortification of certain food items. Which of the following
management. a feeding program. is among these food items?
98. Which of the following signs will indicate that a D. Keep the infant in your health center for close C. Make a teaching plan for the mother, focusing on A. Sugar
young child is suffering from severe pneumonia? observation. menu planning for her child. B. Bread
A. Dyspnea Answer: (B) Supervise the mother in giving 200 to 400 D. Assess and treat the child for health problems like C. Margarine
B. Wheezing ml. of Oresol in 4 hours. infections and intestinal parasitism. D. Filled milk
C. Fast breathing In the IMCI management guidelines, SOME
D. Chest indrawing DEHYDRATION is treated with the administration of Answer: (A) Refer the child urgently to a hospital for Answer: (A) Sugar
Oresol within a period of 4 hours. The amount of Oresol confinement. R.A. 8976 mandates fortification of rice, wheat flour,
Answer: (D) Chest indrawing is best computed on the basis of the child’s weight (75 “Baggy pants” is a sign of severe marasmus. The best sugar and cooking oil with Vitamin A, iron and/or iodine.
In IMCI, chest indrawing is used as the positive sign of ml/kg body weight). If the weight is unknown, the management is urgent referral to a hospital.
dyspnea, indicating severe pneumonia. amount of Oresol is based on the child’s age. 109. What is the best course of action when there is a
105. During the physical examination of a young child, measles epidemic in a nearby municipality?
99. Using IMCI guidelines, you classify a child as having 102. A mother is using Oresol in the management of what is the earliest sign of xerophthalmia that you may A. Give measles vaccine to babies aged 6 to 8 months.
severe pneumonia. What is the best management for diarrhea of her 3-year old child. She asked you what to observe? B. Give babies aged 6 to 11 months one dose of 100,000
the child? do if her child vomits. You will tell her to A. Keratomalacia I.U. of Retinol
A. Prescribe an antibiotic. A. Bring the child to the nearest hospital for further B. Corneal opacity C. Instruct mothers to keep their babies at home to
B. Refer him urgently to the hospital. assessment. C. Night blindness prevent disease transmission.
C. Instruct the mother to increase fluid intake. B. Bring the child to the health center for intravenous D. Conjunctival xerosis D. Instruct mothers to feed their babies adequately to
D. Instruct the mother to continue breastfeeding. fluid therapy. enhance their babies’ resistance.
C. Bring the child to the health center for assessment by Answer: (D) Conjunctival xerosis
Answer: (B) Refer him urgently to the hospital. the physician. The earliest sign of Vitamin A deficiency (xerophthalmia) Answer: (A) Give measles vaccine to babies aged 6 to 8
Severe pneumonia requires urgent referral to a hospital. D. Let the child rest for 10 minutes then continue giving is night blindness. However, this is a functional change, months.
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Ordinarily, measles vaccine is given at 9 months of age. weeks or more not attributed to other conditions; 120. Which of the following clients should be classified
During an impending epidemic, however, one dose may 113. The following are strategies implemented by the progressive, unexplained weight loss; night sweats; and as a case of multibacillary leprosy?
be given to babies aged 6 to 8 months. The mother is Department of Health to prevent mosquito-borne hemoptysis. A. 3 skin lesions, negative slit skin smear
instructed that the baby needs another dose when the diseases. Which of these is most effective in the control B. 3 skin lesions, positive slit skin smear
baby is 9 months old. of Dengue fever? 117. Which clients are considered targets for DOTS C. 5 skin lesions, negative slit skin smear
A. Stream seeding with larva-eating fish Category I? D. 5 skin lesions, positive slit skin smear
110. A mother brought her daughter, 4 years old, to the B. Destroying breeding places of mosquitoes A. Sputum negative cavitary cases
RHU because of cough and colds. Following the IMCI C. Chemoprophylaxis of non-immune persons going to B. Clients returning after a default Answer: (D) 5 skin lesions, positive slit skin smear
assessment guide, which of the following is a danger sign endemic areas C. Relapses and failures of previous PTB treatment A multibacillary leprosy case is one who has a positive
that indicates the need for urgent referral to a hospital? D. Teaching people in endemic areas to use chemically regimens slit skin smear and at least 5 skin lesions.
A. Inability to drink treated mosquito nets D. Clients diagnosed for the first time through a positive
B. High grade fever sputum exam 121. In the Philippines, which condition is the most
C. Signs of severe dehydration Answer: (B) Destroying breeding places of mosquitoes frequent cause of death associated with schistosomiasis?
D. Cough for more than 30 days Aedes aegypti, the vector of Dengue fever, breeds in Answer: (D) Clients diagnosed for the first time through A. Liver cancer
stagnant, clear water. Its feeding time is usually during a positive sputum exam B. Liver cirrhosis
Answer: (A) Inability to drink the daytime. It has a cyclical pattern of occurrence, Category I is for new clients diagnosed by sputum C. Bladder cancer
A sick child aged 2 months to 5 years must be referred unlike malaria which is endemic in certain parts of the examination and clients diagnosed to have a serious D. Intestinal perforation
urgently to a hospital if he/she has one or more of the country. form of extrapulmonary tuberculosis, such as TB
following signs: not able to feed or drink, vomits osteomyelitis. Answer: (B) Liver cirrhosis
everything, convulsions, abnormally sleepy or difficult to 114. Secondary prevention for malaria includes The etiologic agent of schistosomiasis in the Philippines
awaken. A. Planting of neem or eucalyptus trees 118. To improve compliance to treatment, what is Schistosoma japonicum, which affects the small
B. Residual spraying of insecticides at night innovation is being implemented in DOTS? intestine and the liver. Liver damage is a consequence of
111. Management of a child with measles includes the C. Determining whether a place is endemic or not A. Having the health worker follow up the client at home fibrotic reactions to schistosoma eggs in the liver.
administration of which of the following? D. Growing larva-eating fish in mosquito breeding places B. Having the health worker or a responsible family
A. Gentian violet on mouth lesions member monitor drug intake 122. What is the most effective way of controlling
B. Antibiotics to prevent pneumonia Answer: (C) Determining whether a place is endemic or C. Having the patient come to the health center every schistosomiasis in an endemic area?
C. Tetracycline eye ointment for corneal opacity not month to get his medications A. Use of molluscicides
D. Retinol capsule regardless of when the last dose was This is diagnostic and therefore secondary level D. Having a target list to check on whether the patient B. Building of foot bridges
given prevention. The other choices are for primary has collected his monthly supply of drugs C. Proper use of sanitary toilets
prevention. D. Use of protective footwear, such as rubber boots
Answer: (D) Retinol capsule regardless of when the last Answer: (B) Having the health worker or a responsible
dose was given 115. Scotch tape swab is done to check for which family member monitor drug intake Answer: (C) Proper use of sanitary toilets
An infant 6 to 12 months classified as a case of measles intestinal parasite? Directly Observed Treatment Short Course is so-called The ova of the parasite get out of the human body
is given Retinol 100,000 IU; a child is given 200,000 IU A. Ascaris because a treatment partner, preferably a health worker together with feces. Cutting the cycle at this stage is the
regardless of when the last dose was given. B. Pinworm accessible to the client, monitors the client’s compliance most effective way of preventing the spread of the
C. Hookworm to the treatment. disease to susceptible hosts.
112. A mother brought her 10 month old infant for D. Schistosoma
consultation because of fever, which started 4 days prior 119. Diagnosis of leprosy is highly dependent on 123. When residents obtain water from an artesian well
to consultation. To determine malaria risk, what will you Answer: (B) Pinworm recognition of symptoms. Which of the following is an in the neighborhood, the level of this approved type of
do? Pinworm ova are deposited around the anal orifice. early sign of leprosy? water facility is
A. Do a tourniquet test. A. Macular lesions A. I
B. Ask where the family resides. 116. Which of the following signs indicates the need for B. Inability to close eyelids B. II
C. Get a specimen for blood smear. sputum examination for AFB? C. Thickened painful nerves C. III
D. Ask if the fever is present everyday. A. Hematemesis D. Sinking of the nosebridge D. IV
B. Fever for 1 week
Answer: (B) Ask where the family resides. C. Cough for 3 weeks Answer: (C) Thickened painful nerves Answer: (B) II
Because malaria is endemic, the first question to D. Chest pain for 1 week The lesion of leprosy is not macular. It is characterized by A communal faucet or water standpost is classified as
determine malaria risk is where the client’s family a change in skin color (either reddish or whitish) and loss Level II.
resides. If the area of residence is not a known endemic Answer: (C) Cough for 3 weeks of sensation, sweating and hair growth over the lesion.
area, ask if the child had traveled within the past 6 A client is considered a PTB suspect when he has cough Inability to close the eyelids (lagophthalmos) and sinking 124. For prevention of hepatitis A, you decided to
months, where he/she was brought and whether he/she for 2 weeks or more, plus one or more of the following of the nosebridge are late symptoms. conduct health education activities. Which of the
stayed overnight in that area. signs: fever for 1 month or more; chest pain lasting for 2 following is IRRELEVANT?
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A. Use of sterile syringes and needles Oresol/orem. When the foregoing measures are not Answer: (D) Measles 136. Mosquito-borne diseases are prevented mostly
B. Safe food preparation and food handling by vendors possible or effective, tehn urgent referral to the hospital Viral conjunctivitis is transmitted by direct or indirect with the use of mosquito control measures. Which of the
C. Proper disposal of human excreta and personal is done. contact with discharges from infected eyes. Acute following is NOT appropriate for malaria control?
hygiene poliomyelitis is spread through the fecal-oral route and A. Use of chemically treated mosquito nets
D. Immediate reporting of water pipe leaks and illegal 129. A client was diagnosed as having Dengue fever. You contact with throat secretions, whereas diphtheria is B. Seeding of breeding places with larva-eating fish
water connections will say that there is slow capillary refill when the color through direct and indirect contact with respiratory C. Destruction of breeding places of the mosquito vector
of the nailbed that you pressed does not return within secretions. D. Use of mosquito-repelling soaps, such as those with
Answer: (A) Use of sterile syringes and needles how many seconds? basil or citronella
Hepatitis A is transmitted through the fecal oral route. A. 3 133. Among children aged 2 months to 3 years, the most
Hepatitis B is transmitted through infected body B. 5 prevalent form of meningitis is caused by which Answer: (C) Destruction of breeding places of the
secretions like blood and semen. C. 8 microorganism? mosquito vector
D. 10 A. Hemophilus influenzae Anopheles mosquitoes breed in slow-moving, clear
126. Which biological used in Expanded Program on B. Morbillivirus water, such as mountain streams.
Immunization (EPI) should NOT be stored in the freezer? Answer: (A) 3 C. Steptococcus pneumoniae
A. DPT Adequate blood supply to the area allows the return of D. Neisseria meningitidis 137. A 4-year old client was brought to the health center
B. Oral polio vaccine the color of the nailbed within 3 seconds. with the chief complaint of severe diarrhea and the
C. Measles vaccine Answer: (A) Hemophilus influenzae passage of “rice water” stools. The client is most
D. MMR 130. A 3-year old child was brought by his mother to the Hemophilus meningitis is unusual over the age of 5 probably suffering from which condition?
health center because of fever of 4-day duration. The years. In developing countries, the peak incidence is in A. Giardiasis
Answer: (A) DPT child had a positive tourniquet test result. In the absence children less than 6 months of age. Morbillivirus is the B. Cholera
DPT is sensitive to freezing. The appropriate storage of other signs, which is the most appropriate measure etiology of measles. Streptococcus pneumoniae and C. Amebiasis
temperature of DPT is 2 to 8° C only. OPV and measles that the PHN may carry out to prevent Dengue shock Neisseria meningitidis may cause meningitis, but age D. Dysentery
vaccine are highly sensitive to heat and require freezing. syndrome? distribution is not specific in young children.
MMR is not an immunization in the Expanded Program A. Insert an NGT and give fluids per NGT. Answer: (B) Cholera
on Immunization. B. Instruct the mother to give the child Oresol. 134. Human beings are the major reservoir of malaria. Passage of profuse watery stools is the major symptom
C. Start the patient on intravenous fluids STAT. Which of the following strategies in malaria control is of cholera. Both amebic and bacillary dysentery are
127. You will conduct outreach immunization in a D. Refer the client to the physician for appropriate based on this fact? characterized by the presence of blood and/or mucus in
barangay with a population of about 1500. Estimate the management. A. Stream seeding the stools. Giardiasis is characterized by fat
number of infants in the barangay. B. Stream clearing malabsorption and, therefore, steatorrhea.
A. 45 Answer: (B) Instruct the mother to give the child C. Destruction of breeding places
B. 50 Oresol. D. Zooprophylaxis 138. In the Philippines, which specie of schistosoma is
C. 55 Since the child does not manifest any other danger sign, endemic in certain regions?
D. 60 maintenance of fluid balance and replacement of fluid Answer: (D) Zooprophylaxis A. S. mansoni
loss may be done by giving the client Oresol. Zooprophylaxis is done by putting animals like cattle or B. S. japonicum
Answer: (A) 45 dogs close to windows or doorways just before nightfall. C. S. malayensis
To estimate the number of infants, multiply total 131. The pathognomonic sign of measles is Koplik’s spot. The Anopheles mosquito takes his blood meal from the D. S. haematobium
population by 3%. You may see Koplik’s spot by inspecting the _____. animal and goes back to its breeding place, thereby
A. Nasal mucosa preventing infection of humans. Answer: (B) S. japonicum
128. In Integrated Management of Childhood Illness, B. Buccal mucosa S. mansoni is found mostly in Africa and South America;
severe conditions generally require urgent referral to a C. Skin on the abdomen 135. The use of larvivorous fish in malaria control is the S. haematobium in Africa and the Middle East; and S.
hospital. Which of the following severe conditions DOES D. Skin on the antecubital surface basis for which strategy of malaria control? malayensis only in peninsular Malaysia.
NOT always require urgent referral to a hospital? A. Stream seeding
A. Mastoiditis Answer: (B) Buccal mucosa B. Stream clearing 139. A 32-year old client came for consultation at the
B. Severe dehydration Koplik’s spot may be seen on the mucosa of the mouth C. Destruction of breeding places health center with the chief complaint of fever for a
C. Severe pneumonia or the throat. D. Zooprophylaxis week. Accompanying symptoms were muscle pains and
D. Severe febrile disease body malaise. A week after the start of fever, the client
132. Among the following diseases, which is airborne? Answer: (A) Stream seeding noted yellowish discoloration of his sclera. History
Answer: (B) Severe dehydration A. Viral conjunctivitis Stream seeding is done by putting tilapia fry in streams showed that he waded in flood waters about 2 weeks
The order of priority in the management of severe B. Acute poliomyelitis or other bodies of water identified as breeding places of before the onset of symptoms. Based on his history,
dehydration is as follows: intravenous fluid therapy, C. Diphtheria the Anopheles mosquito which disease condition will you suspect?
referral to a facility where IV fluids can be initiated D. Measles A. Hepatitis A
within 30 minutes, Oresol/nasogastric tube, B. Hepatitis B
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C. Tetanus Transmission occurs mostly through sexual intercourse A. Advice them on the signs of German measles. children. Complications, such as pneumonia, are higher
D. Leptospirosis and exposure to blood or tissues. B. Avoid crowded places, such as markets and in incidence in adults.
moviehouses.
Answer: (D) Leptospirosis 143. The most frequent causes of death among clients C. Consult at the health center where rubella vaccine 149. Complications to infectious parotitis (mumps) may
Leptospirosis is transmitted through contact with the with AIDS are opportunistic diseases. Which of the may be given. be serious in which type of clients?
skin or mucous membrane with water or moist soil following opportunistic infections is characterized by D. Consult a physician who may give them rubella A. Pregnant women
contaminated with urine of infected animals, like rats. tonsillopharyngitis? immunoglobulin. B. Elderly clients
A. Respiratory candidiasis C. Young adult males
140. MWSS provides water to Manila and other cities in B. Infectious mononucleosis Answer: (D) Consult a physician who may give them D. Young infants
Metro Manila. This is an example of which level of water C. Cytomegalovirus disease rubella immunoglobulin.
facility? D. Pneumocystis carinii pneumonia Rubella vaccine is made up of attenuated German Answer: (C) Young adult males
A. I measles viruses. This is contraindicated in pregnancy. Epididymitis and orchitis are possible complications of
B. II Answer: (B) Infectious mononucleosis Immune globulin, a specific prophylactic against German mumps. In post-adolescent males, bilateral inflammation
C. III Cytomegalovirus disease is an acute viral disease measles, may be given to pregnant women. of the testes and epididymis may cause sterility.
D. IV characterized by fever, sore throat and
lymphadenopathy. 147. You were invited to be the resource person in a
Answer: (C) III training class for food handlers. Which of the following
Waterworks systems, such as MWSS, are classified as 144. To determine possible sources of sexually would you emphasize regarding prevention of
level III. transmitted infections, which is the BEST method that staphylococcal food poisoning?
may be undertaken by the public health nurse? A. All cooking and eating utensils must be thoroughly
141. You are the PHN in the city health center. A client A. Contact tracing washed.
underwent screening for AIDS using ELISA. His result was B. Community survey B. Food must be cooked properly to destroy
positive. What is the best course of action that you may C. Mass screening tests staphylococcal microorganisms.
take? D. Interview of suspects C. Food handlers and food servers must have a negative
A. Get a thorough history of the client, focusing on the stool examination result.
practice of high risk behaviors. Answer: (A) Contact tracing D. Proper handwashing during food preparation is the
B. Ask the client to be accompanied by a significant Contact tracing is the most practical and reliable method best way of preventing the condition.
person before revealing the result. of finding possible sources of person-to-person
C. Refer the client to the physician since he is the best transmitted infections, such as sexually transmitted Answer: (D) Proper handwashing during food
person to reveal the result to the client. diseases. preparation is the best way of preventing the
D. Refer the client for a supplementary test, such as condition.
Western blot, since the ELISA result may be false. 145. Antiretroviral agents, such as AZT, are used in the Symptoms of this food poisoning are due to
management of AIDS. Which of the following is NOT an staphylococcal enterotoxin, not the microorganisms
Answer: (D) Refer the client for a supplementary test, action expected of these drugs. themselves. Contamination is by food handling by
such as Western blot, since the ELISA result may be A. They prolong the life of the client with AIDS. persons with staphylococcal skin or eye infections.
false. B. They reduce the risk of opportunistic infections
A client having a reactive ELISA result must undergo a C. They shorten the period of communicability of the 148. In a mothers’ class, you discussed childhood
more specific test, such as Western blot. A negative disease. diseases such as chicken pox. Which of the following
supplementary test result means that the ELISA result D. They are able to bring about a cure of the disease statements about chicken pox is correct?
was false and that, most probably, the client is not condition. A. The older one gets, the more susceptible he becomes
infected. to the complications of chicken pox.
Answer: (D) They are able to bring about a cure of the B. A single attack of chicken pox will prevent future
142. Which is the BEST control measure for AIDS? disease condition. episodes, including conditions such as shingles.
A. Being faithful to a single sexual partner There is no known treatment for AIDS. Antiretroviral C. To prevent an outbreak in the community, quarantine
B. Using a condom during each sexual contact agents reduce the risk of opportunistic infections and may be imposed by health authorities.
C. Avoiding sexual contact with commercial sex workers prolong life, but does not cure the underlying D. Chicken pox vaccine is best given when there is an
D. Making sure that one’s sexual partner does not have immunodeficiency. impending outbreak in the community.
signs of AIDS
146. A barangay had an outbreak of German measles. To Answer: (A) The older one gets, the more susceptible
Answer: (A) Being faithful to a single sexual partner prevent congenital rubella, what is the BEST advice that he becomes to the complications of chicken pox.
Sexual fidelity rules out the possibility of getting the you can give to women in the first trimester of Chicken pox is usually more severe in adults than in
disease by sexual contact with another infected person. pregnancy in the barangay?
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MEDICAL SURGICAL NURSING Part 1 8. Dr. Marquez orders a continuous intravenous d. Monitor clients temperature every hour male client will go home with a prescription for which
nitroglycerin infusion for the client suffering from 14. Kate who has undergone mitral valve replacement medication?
1. Mrs. Chua a 78 year old client is admitted with the myocardial infarction. Which of the following is the most suddenly experiences continuous bleeding from the a. Paracetamol
diagnosis of mild chronic heart failure. The nurse expects essential nursing action? surgical incision during postoperative period. Which of b. Ibuprofen
to hear when listening to client’s lungs indicative of a. Monitoring urine output frequently the following pharmaceutical agents should Nurse Aiza c. Nitroglycerin
chronic heart failure would be: b. Monitoring blood pressure every 4 hours prepare to administer to Kate? d. Nicotine (Nicotrol)
a. Stridor c. Obtaining serum potassium levels daily a. Protamine Sulfate 21. Nurse Lilly has been assigned to a client with
b. Crackles d. Obtaining infusion pump for the medication b. Quinidine Sulfate Raynaud’s disease. Nurse Lilly realizes that the etiology
c. Wheezes 9. During the second day of hospitalization of the client c. Vitamin C of the disease is unknown but it is characterized by:
d. Friction rubs after a Myocardial Infarction. Which of the following is d. Coumadin a. Episodic vasospastic disorder of capillaries
2. Patrick who is hospitalized following a myocardial an expected outcome? 15. In reducing the risk of endocarditis, good dental care b. Episodic vasospastic disorder of small veins
infarction asks the nurse why he is taking morphine. The a. Able to perform self-care activities without pain is an important measure. To promote good dental care c. Episodic vasospastic disorder of the aorta
nurse explains that morphine: b. Severe chest pain in client with mitral stenosis in teaching plan should d. Episodic vasospastic disorder of the small arteries
a. Decrease anxiety and restlessness c. Can recognize the risk factors of Myocardial Infarction include proper use of… 22. Nurse Jamie should explain to male client with
b. Prevents shock and relieves pain d. Can Participate in cardiac rehabilitation walking a. Dental floss diabetes that self-monitoring of blood glucose is
c. Dilates coronary blood vessels program b. Electric toothbrush preferred to urine glucose testing because…
d. Helps prevent fibrillation of the heart 10. A 68 year old client is diagnosed with a right-sided c. Manual toothbrush a. More accurate
3. Which of the following should the nurse teach the brain attack and is admitted to the hospital. In caring for d. Irrigation device b. Can be done by the client
client about the signs of digitalis toxicity? this client, the nurse should plan to: 16. Among the following signs and symptoms, which c. It is easy to perform
a. Increased appetite a. Application of elastic stockings to prevent flaccid by would most likely be present in a client with mitral d. It is not influenced by drugs
b. Elevated blood pressure muscle gurgitation? 23. Jessie weighed 210 pounds on admission to the
c. Skin rash over the chest and back b. Use hand roll and extend the left upper extremity on a a. Altered level of consciousness hospital. After 2 days of diuretic therapy, Jessie weighs
d. Visual disturbances such as seeing yellow spots pillow to prevent contractions b. Exceptional Dyspnea 205.5 pounds. The nurse could estimate the amount of
4. Nurse Trisha teaches a client with heart failure to take c. Use a bed cradle to prevent dorsiflexion of feet c. Increase creatine phospholinase concentration fluid Jessie has lost…
oral Furosemide in the morning. The reason for this is to d. Do passive range of motion exercise d. Chest pain a. 0.3 L
help… 11. Nurse Liza is assigned to care for a client who has 17. Kris with a history of chronic infection of the urinary b. 1.5 L
a. Retard rapid drug absorption returned to the nursing unit after left nephrectomy. system complains of urinary frequency and burning c. 2.0 L
b. Excrete excessive fluids accumulated at night Nurse Liza’s highest priority would be… sensation. To figure out whether the current problem is d. 3.5 L
c. Prevents sleep disturbances during night a. Hourly urine output in renal origin, the nurse should assess whether the 24. Nurse Donna is aware that the shift of body fluids
d. Prevention of electrolyte imbalance b. Temperature client has discomfort or pain in the… associated with Intravenous administration of albumin
5. What would be the primary goal of therapy for a client c. Able to turn side to side a. Urinary meatus occurs in the process of:
with pulmonary edema and heart failure? d. Able to sips clear liquid b. Pain in the Labium a. Osmosis
a. Enhance comfort 12. A 64 year old male client with a long history of c. Suprapubic area b. Diffusion
b. Increase cardiac output cardiovascular problem including hypertension and d. Right or left costovertebral angle c. Active transport
c. Improve respiratory status angina is to be scheduled for cardiac catheterization. 18. Nurse Perry is evaluating the renal function of a male d. Filtration
d. Peripheral edema decreased During pre cardiac catheterization teaching, Nurse client. After documenting urine volume and 25. Myrna a 52 year old client with a fractured left tibia
6. Nurse Linda is caring for a client with head injury and Cherry should inform the client that the primary purpose characteristics, Nurse Perry assesses which signs as the has a long leg cast and she is using crutches to ambulate.
monitoring the client with decerebrate posturing. Which of the procedure is….. best indicator of renal function. Nurse Joy assesses for which sign and symptom that
of the following is a characteristic of this type of a. To determine the existence of CHD a. Blood pressure indicates complication associated with crutch walking?
posturing? b. To visualize the disease process in the coronary b. Consciousness a. Left leg discomfort
a. Upper extremity flexion with lower extremity flexion arteries c. Distension of the bladder b. Weak biceps brachii
b. Upper extremity flexion with lower extremity c. To obtain the heart chambers pressure d. Pulse rate c. Triceps muscle spasm
extension d. To measure oxygen content of different heart 19. John suddenly experiences a seizure, and Nurse Gina d. Forearm weakness
c. Extension of the extremities after a stimulus chambers notice that John exhibits uncontrollable jerking 26. Which of the following statements should the nurse
d. Flexion of the extremities after stimulus 13. During the first several hours after a cardiac movements. Nurse Gina documents that John teach the neutropenic client and his family to avoid?
7. A female client is taking Cascara Sagrada. Nurse Betty catheterization, it would be most essential for nurse experienced which type of seizure? a. Performing oral hygiene after every meal
informs the client that the following maybe experienced Cherry to… a. Tonic seizure b. Using suppositories or enemas
as side effects of this medication: a. Elevate clients bed at 45° b. Absence seizure c. Performing perineal hygiene after each bowel
a. GI bleeding b. Instruct the client to cough and deep breathe every 2 c. Myoclonic seizure movement
b. Peptic ulcer disease hours d. Clonic seizure d. Using a filter mask
c. Abdominal cramps c. Frequently monitor client’s apical pulse and blood 20. Smoking cessation is critical strategy for the client 27. A female client is experiencing painful and rigid
d. Partial bowel obstruction pressure with Burgher’s disease, Nurse Jasmin anticipates that the abdomen and is diagnosed with perforated peptic ulcer.
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A surgery has been scheduled and a nasogastric tube is 34. Nurse Lucy is planning to give pre operative teaching d. “Most people can tolerate regular diet after this type 46. Nurse Jenny is instilling an otic solution into an adult
inserted. The nurse should place the client before to a client who will be undergoing rhinoplasty. Which of of surgery” male client left ear. Nurse Jenny avoids doing which of
surgery in the following should be included? 40. Nurse Rachel teaches a client who has been recently the following as part of the procedure
a. Sims position a. Results of the surgery will be immediately noticeable diagnosed with hepatitis A about untoward signs and a. Pulling the auricle backward and upward
b. Supine position postoperatively symptoms related to Hepatitis that may develop. The b. Warming the solution to room temperature
c. Semi-fowlers position b. Normal saline nose drops will need to be administered one that should be reported immediately to the c. Pacing the tip of the dropper on the edge of ear canal
d. Dorsal recumbent position preoperatively physician is: d. Placing client in side lying position
28. Which nursing intervention ensures adequate c. After surgery, nasal packing will be in place 8 to 10 a. Restlessness 47. Nurse Bea should instruct the male client with an
ventilating exchange after surgery? days b. Yellow urine ileostomy to report immediately which of the following
a. Remove the airway only when client is fully conscious d. Aspirin containing medications should not be taken 14 c. Nausea symptom?
b. Assess for hypoventilation by auscultating the lungs days before surgery d. Clay- colored stools a. Absence of drainage from the ileostomy for 6 or more
c. Position client laterally with the neck extended 35. Paul is admitted to the hospital due to metabolic 41. Which of the following antituberculosis drugs can hours
d. Maintain humidified oxygen via nasal canula acidosis caused by Diabetic ketoacidosis (DKA). The damage the 8th cranial nerve? b. Passage of liquid stool in the stoma
29. George who has undergone thoracic surgery has nurse prepares which of the following medications as an a. Isoniazid (INH) c. Occasional presence of undigested food
chest tube connected to a water-seal drainage system initial treatment for this problem? b. Paraoaminosalicylic acid (PAS) d. A temperature of 37.6 °C
attached to suction. Presence of excessive bubbling is a. Regular insulin c. Ethambutol hydrochloride (myambutol) 48. Jerry has diagnosed with appendicitis. He develops a
identified in water-seal chamber, the nurse should… b. Potassium d. Streptomycin fever, hypotension and tachycardia. The nurse suspects
a. “Strip” the chest tube catheter c. Sodium bicarbonate 42. The client asks Nurse Annie the causes of peptic which of the following complications?
b. Check the system for air leaks d. Calcium gluconate ulcer. Nurse Annie responds that recent research a. Intestinal obstruction
c. Recognize the system is functioning correctly 36. Dr. Marquez tells a client that an increase intake of indicates that peptic ulcers are the result of which of the b. Peritonitis
d. Decrease the amount of suction pressure foods that are rich in Vitamin E and beta-carotene are following: c. Bowel ischemia
30. A client who has been diagnosed of hypertension is important for healthier skin. The nurse teaches the client a. Genetic defect in gastric mucosa d. Deficient fluid volume
being taught to restrict intake of sodium. The nurse that excellent food sources of both of these substances b. Stress 49. Which of the following compilations should the nurse
would know that the teachings are effective if the client are: c. Diet high in fat carefully monitors a client with acute pancreatitis.
states that… a. Fish and fruit jam d. Helicobacter pylori infection a. Myocardial Infarction
a. I can eat celery sticks and carrots b. Oranges and grapefruit 43. Ryan has undergone subtotal gastrectomy. The nurse b. Cirrhosis
b. I can eat broiled scallops c. Carrots and potatoes should expect that nasogastric tube drainage will be c. Peptic ulcer
c. I can eat shredded wheat cereal d. Spinach and mangoes what color for about 12 to 24 hours after surgery? d. Pneumonia
d. I can eat spaghetti on rye bread 37. A client has Gastroesophageal Reflux Disease (GERD). a. Bile green 50. Which of the following symptoms during the icteric
31. A male client with a history of cirrhosis and The nurse should teach the client that after every meals, b. Bright red phase of viral hepatitis should the nurse expect the
alcoholism is admitted with severe dyspnea resulted to the client should… c. Cloudy white client to inhibit?
ascites. The nurse should be aware that the ascites is a. Rest in sitting position d. Dark brown a. Watery stool
most likely the result of increased… b. Take a short walk 44. Nurse Joan is assigned to come for client who has b. Yellow sclera
a. Pressure in the portal vein c. Drink plenty of water just undergone eye surgery. Nurse Joan plans to teach c. Tarry stool
b. Production of serum albumin d. Lie down at least 30 minutes the client activities that are permitted during the post d. Shortness of breath
c. Secretion of bile salts 38. After gastroscopy, an adaptation that indicates major operative period. Which of the following is best
d. Interstitial osmotic pressure complication would be: recommended for the client?
32. A newly admitted client is diagnosed with Hodgkin’s a. Nausea and vomiting a. Watching circus
disease undergoes an excisional cervical lymph node b. Abdominal distention b. Bending over
biopsy under local anesthesia. What does the nurse c. Increased GI motility c. Watching TV
assess first after the procedure? d. Difficulty in swallowing d. Lifting objects
a. Vital signs 39. A client who has undergone a cholecystectomy asks 45. A client suffered from a lower leg injury and seeks
b. Incision site the nurse whether there are any dietary restrictions that treatment in the emergency room. There is a prominent
c. Airway must be followed. Nurse Hilary would recognize that the deformity to the lower aspect of the leg, and the injured
d. Level of consciousness dietary teaching was well understood when the client leg appears shorter that the other leg. The affected leg is
33. A client has 15% blood loss. Which of the following tells a family member that: painful, swollen and beginning to become ecchymotic.
nursing assessment findings indicates hypovolemic a. “Most people need to eat a high protein diet for 12 The nurse interprets that the client is experiencing:
shock? months after surgery” a. Fracture
a. Systolic blood pressure less than 90mm Hg b. “I should not eat those foods that upset me before the b. Strain
b. Pupils unequally dilated surgery” c. Sprain
c. Respiratory rate of 4 breath/min c. “I should avoid fatty foods as long as I live” d. Contusion
d. Pulse rate less than 60bpm
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ANSWERS and RATIONALES for MEDICAL SURGICAL gums, allowing bacteria to enter and increasing inflammation may have closed in on the airway 49. D. A client with acute pancreatitis is prone to
NURSING Part 1 the risk of endocarditis. leading to ineffective air exchange. complications associated with respiratory
16. B. Weight gain due to retention of fluids and 33. A. Typical signs and symptoms of hypovolemic system.
1. B. Left sided heart failure causes fluid worsening heart failure causes exertional shock includes systolic blood pressure of less 50. B. Liver inflammation and obstruction block the
accumulation in the capillary network of the dyspnea in clients with mitral regurgitation. than 90 mm Hg. normal flow of bile. Excess bilirubin turns the
lung. Fluid eventually enters alveolar spaces and 17. D. Discomfort or pain is a problem that 34. D. Aspirin containing medications should not be skin and sclera yellow and the urine dark and
causes crackling sounds at the end of inspiration. originates in the kidney. It is felt at the taken 14 days before surgery to decrease the frothy.
2. B. Morphine is a central nervous system costovertebral angle on the affected side. risk of bleeding.
depressant used to relieve the pain associated 18. A. Perfusion can be best estimated by blood 35. A. Metabolic acidosis is anaerobic metabolism
with myocardial infarction, it also decreases pressure, which is an indirect reflection of the caused by lack of ability of the body to use
apprehension and prevents cardiogenic shock. adequacy of cardiac output. circulating glucose. Administration of insulin
3. D. Seeing yellow spots and colored vision are 19. C. Myoclonic seizure is characterized by sudden corrects this problem.
common symptoms of digitalis toxicity uncontrollable jerking movements of a single or 36. D. Beta-carotene and Vitamin E are antioxidants
4. C. When diuretics are taken in the morning, multiple muscle group. which help to inhibit oxidation. Vitamin E is
client will void frequently during daytime and 20. D. Nicotine (Nicotrol) is given in controlled and found in the following foods: wheat germ, corn,
will not need to void frequently at night. decreasing doses for the management of nuts, seeds, olives, spinach, asparagus and other
5. B. The primary goal of therapy for the client with nicotine withdrawal syndrome. green leafy vegetables. Food sources of beta-
pulmonary edema or heart failure is increasing 21. D. Raynaud’s disease is characterized by carotene include dark green vegetables, carrots,
cardiac output. Pulmonary edema is an acute vasospasms of the small cutaneous arteries that mangoes and tomatoes.
medical emergency requiring immediate involves fingers and toes. 37. A. Gravity speeds up digestion and prevents
intervention. 22. A. Urine testing provides an indirect measure reflux of stomach contents into the esophagus.
6. C. Decerebrate posturing is the extension of the that maybe influenced by kidney function while 38. B. Abdominal distension may be associated with
extremities after a stimulus, which may occur blood glucose testing is a more direct and pain, may indicate perforation, a complication
with upper brain stem injury. accurate measure. that could lead to peritonitis.
7. C. The most frequent side effects of Cascara 23. C. One liter of fluid approximately weighs 2.2 39. D. It may take 4 to 6 months to eat anything, but
Sagrada (Laxative) is abdominal cramps and pounds. A 4.5 pound weight loss equals to most people can eat anything they want.
nausea. approximately 2L. 40. D. Clay colored stools are indicative of hepatic
8. D. Administration of Intravenous Nitroglycerin 24. A. Osmosis is the movement of fluid from an obstruction
infusion requires pump for accurate control of area of lesser solute concentration to an area of 41. D. Streptomycin is an aminoglycoside and
medication. greater solute concentration. damage on the 8th cranial nerve (ototoxicity) is a
9. A. By the 2nd day of hospitalization after 25. D. Forearm muscle weakness is a probable sign common side effect of aminoglycosides.
suffering a Myocardial Infarction, Clients are of radial nerve injury caused by crutch pressure 42. D. Most peptic ulcer is caused by Helicopter
able to perform care without chest pain on the axillae. pylori which is a gram negative bacterium.
10. B. The left side of the body will be affected in a 26. B. Neutropenic client is at risk for infection 43. D. 12 to 24 hours after subtotal gastrectomy
right-sided brain attack. especially bacterial infection of the gastric drainage is normally brown, which
11. A. After nephrectomy, it is necessary to measure gastrointestinal and respiratory tract. indicates digested food.
urine output hourly. This is done to assess the 27. C. Semi-fowlers position will localize the spilled 44. C. Watching TV is permissible because the eye
effectiveness of the remaining kidney also to stomach contents in the lower part of the does not need to move rapidly with this activity,
detect renal failure early. abdominal cavity. and it does not increase intraocular pressure.
12. B. The lumen of the arteries can be assessed by 28. C. Positioning the client laterally with the neck 45. A. Common signs and symptoms of fracture
cardiac catheterization. Angina is usually caused extended does not obstruct the airway so that include pain, deformity, shortening of the
by narrowing of the coronary arteries. drainage of secretions and oxygen and carbon extremity, crepitus and swelling.
13. C. Blood pressure is monitored to detect dioxide exchange can occur. 46. C. The dropper should not touch any object or
hypotension which may indicate shock or 29. B. Excessive bubbling indicates an air leak which any part of the client’s ear.
hemorrhage. Apical pulse is taken to detect must be eliminated to permit lung expansion. 47. A. Sudden decrease in drainage or onset of
dysrhythmias related to cardiac irritability. 30. C. Wheat cereal has a low sodium content. severe abdominal pain should be reported
14. A. Protamine Sulfate is used to prevent 31. A. Enlarged cirrhotic liver impinges the portal immediately to the physician because it could
continuous bleeding in client who has system causing increased hydrostatic pressure mean that obstruction has been developed.
undergone open heart surgery. resulting to ascites. 48. B. Complications of acute appendicitis are
15. C. The use of electronic toothbrush, irrigation 32. C. Assessing for an open airway is the priority. peritonitis, perforation and abscess
device or dental floss may cause bleeding of The procedure involves the neck, the anesthesia development.
may have affected the swallowing reflex or the
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MEDICAL SURGICAL NURSING Part 2 c. Protects the client’s head from injury c. Ascites 22. The nurse is assessing a client with pleural effusion.
d. Attempt to insert a tongue depressor between the d. Jaundice The nurse expect to find:
1. A client is scheduled for insertion of an inferior vena client’s teeth 15. A client is suspected to develop tetany after a a. Deviation of the trachea towards the involved side
cava (IVC) filter. Nurse Patricia consults the physician 8. A client has undergone right pneumonectomy. When subtotal thyroidectomy. Which of the following b. Reduced or absent of breath sounds at the base of the
about withholding which regularly scheduled medication turning the client, the nurse should plan to position the symptoms might indicate tetany? lung
on the day before the surgery? client either: a. Tingling in the fingers c. Moist crackles at the posterior of the lungs
a. Potassium Chloride a. Right side-lying position or supine b. Pain in hands and feet d. Increased resonance with percussion of the involved
b. Warfarin Sodium b. High fowlers c. Tension on the suture lines area
c. Furosemide c. Right or left side lying position d. Bleeding on the back of the dressing 23. A client admitted with newly diagnosed with
d. Docusate d. Low fowler’s position 16. A 58 year old woman has newly diagnosed with Hodgkin’s disease. Which of the following would the
2. A nurse is planning to assess the corneal reflex on 9. Nurse Jenny should caution a female client who is hypothyroidism. The nurse is aware that the signs and nurse expect the client to report?
unconscious client. Which of the following is the safest sexually active in taking Isoniazid (INH) because the drug symptoms of hypothyroidism include: a. Lymph node pain
stimulus to touch the client’s cornea? has which of the following side effects? a. Diarrhea b. Weight gain
a. Cotton buds a. Prevents ovulation b. Vomiting c. Night sweats
b. Sterile glove b. Has a mutagenic effect on ova c. Tachycardia d. Headache
c. Sterile tongue depressor c. Decreases the effectiveness of oral contraceptives d. Weight gain 24. A client has suffered from fall and sustained a leg
d. Wisp of cotton d. Increases the risk of vaginal infection 17. A client has undergone for an ileal conduit, the nurse injury. Which appropriate question would the nurse ask
3. A female client develops an infection at the catheter 10. A client has undergone gastrectomy. Nurse Jovy is in charge should closely monitor the client for the client to help determine if the injury caused
insertion site. The nurse in charge uses the term aware that the best position for the client is: occurrence of which of the following complications fracture?
“iatrogenic” when describing the infection because it a. Left side lying related to pelvic surgery? a. “Is the pain sharp and continuous?”
resulted from: b. Low fowler’s a. Ascites b. “Is the pain dull ache?”
a. Client’s developmental level c. Prone b. Thrombophlebitis c. “Does the discomfort feel like a cramp?”
b. Therapeutic procedure d. Supine c. Inguinal hernia d. “Does the pain feel like the muscle was stretched?”
c. Poor hygiene 11. During the initial postoperative period of the client’s d. Peritonitis 25. The Nurse is assessing the client’s casted extremity
d. Inadequate dietary patterns stoma. The nurse evaluates which of the following 18. Dr. Marquez is about to defibrillate a client in for signs of infection. Which of the following findings is
4. Nurse Carol is assessing a client with Parkinson’s observations should be reported immediately to the ventricular fibrillation and says in a loud voice “clear”. indicative of infection?
disease. The nurse recognize bradykinesia when the physician? What should be the action of the nurse? a. Edema
client exhibits: a. Stoma is dark red to purple a. Places conductive gel pads for defibrillation on the b. Weak distal pulse
a. Intentional tremor b. Stoma is oozes a small amount of blood client’s chest c. Coolness of the skin
b. Paralysis of limbs c. Stoma is lightly edematous b. Turn off the mechanical ventilator d. Presence of “hot spot” on the cast
c. Muscle spasm d. Stoma does not expel stool c. Shuts off the client’s IV infusion 26. Nurse Rhia is performing an otoscopic examination
d. Lack of spontaneous movement 12. Kate which has diagnosed with ulcerative colitis is d. Steps away from the bed and make sure all others on a female client with a suspected diagnosis of
5. A client who suffered from automobile accident following physician’s order for bed rest with bathroom have done the same mastoiditis. Nurse Rhia would expect to note which of
complains of seeing frequent flashes of light. The nurse privileges. What is the rationale for this activity 19. A client has been diagnosed with glomerulonephritis the following if this disorder is present?
should expect: restriction? complains of thirst. The nurse should offer: a. Transparent tympanic membrane
a. Myopia a. Prevent injury a. Juice b. Thick and immobile tympanic membrane
b. Detached retina b. Promote rest and comfort b. Ginger ale c. Pearly colored tympanic membrane
c. Glaucoma c. Reduce intestinal peristalsis c. Milk shake d. Mobile tympanic membrane
d. Scleroderma d. Conserve energy d. Hard candy 27. Nurse Jocelyn is caring for a client with nasogastric
6. Kate with severe head injury is being monitored by the 13. Nurse KC should regularly assess the client’s ability to 20. A client with acute renal failure is aware that the tube that is attached to low suction. Nurse Jocelyn
nurse for increasing intracranial pressure (ICP). Which metabolize the total parenteral nutrition (TPN) solution most serious complication of this condition is: assesses the client for symptoms of which acid-base
finding should be most indicative sign of increasing adequately by monitoring the client for which of the a. Constipation disorder?
intracranial pressure? following signs: b. Anemia a. Respiratory alkalosis
a. Intermittent tachycardia a. Hyperglycemia c. Infection b. Respiratory acidosis
b. Polydipsia b. Hypoglycemia d. Platelet dysfunction c. Metabolic acidosis
c. Tachypnea c. Hypertension 21. Nurse Karen is caring for clients in the OR. The nurse d. Metabolic alkalosis
d. Increased restlessness d. Elevate blood urea nitrogen concentration is aware that the last physiologic function that the client 28. A male adult client has undergone a lumbar puncture
7. A hospitalized client had a tonic-clonic seizure while 14. A female client has an acute pancreatitis. Which of loss during the induction of anesthesia is: to obtain cerebrospinal fluid (CSF) for analysis. Which of
walking in the hall. During the seizure the nurse priority the following signs and symptoms the nurse would a. Consciousness the following values should be negative if the CSF is
should be: expect to see? b. Gag reflex normal?
a. Hold the clients arms and leg firmly a. Constipation c. Respiratory movement a. Red blood cells
b. Place the client immediately to soft surface b. Hypertension d. Corneal reflex b. White blood cells
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c. Insulin 36. A client with peptic ulcer is being assessed by the b. Meat loaf and strawberries
d. Protein nurse for gastrointestinal perforation. The nurse should c. Tomato soup and apple pie
29. A client is suspected of developing diabetes monitor for: d. Tomato soup and buttered bread
insipidus. Which of the following is the most effective a. (+) guaiac stool test 44. Tony returns form surgery with permanent
assessment? b. Slow, strong pulse colostomy. During the first 24 hours the colostomy does
a. Taking vital signs every 4 hours c. Sudden, severe abdominal pain not drain. The nurse should be aware that:
b. Monitoring blood glucose d. Increased bowel sounds a. Proper functioning of nasogastric suction
c. Assessing ABG values every other day 37. A client has undergone surgery for retinal b. Presurgical decrease in fluid intake
d. Measuring urine output hourly detachment. Which of the following goal should be c. Absence of gastrointestinal motility
30. A 58 year old client is suffering from acute phase of prioritized? d. Intestinal edema following surgery
rheumatoid arthritis. Which of the following would the a. Prevent an increase intraocular pressure 45. When teaching a client about the signs of colorectal
nurse in charge identify as the lowest priority of the plan b. Alleviate pain cancer, Nurse Trish stresses that the most common
of care? c. Maintain darkened room complaint of persons with colorectal cancer is:
a. Prevent joint deformity d. Promote low-sodium diet a. Abdominal pain
b. Maintaining usual ways of accomplishing task 38. A Client with glaucoma has been prescribed with b. Hemorrhoids
c. Relieving pain miotics. The nurse is aware that miotics is for: c. Change in caliber of stools
d. Preserving joint function a. Constricting pupil d. Change in bowel habits
31. Among the following, which client is autotransfusion b. Relaxing ciliary muscle 46. Louis develops peritonitis and sepsis after surgical
possible? c. Constricting intraocular vessel repair of ruptures diverticulum. The nurse in charge
a. Client with AIDS d. Paralyzing ciliary muscle should expect an assessment of the client to reveal:
b. Client with ruptured bowel 39. When suctioning an unconscious client, which a. Tachycardia
c. Client who is in danger of cardiac arrest nursing intervention should the nurse prioritize in b. Abdominal rigidity
d. Client with wound infection maintaining cerebral perfusion? c. Bradycardia
32. Which of the following is not a sign of a. Administer diuretics d. Increased bowel sounds
thromboembolism? b. Administer analgesics 47. Immediately after liver biopsy, the client is placed on
a. Edema c. Provide hygiene the right side, the nurse is aware that that this position
b. Swelling d. Hyperoxygenate before and after suctioning should be maintained because it will:
c. Redness 40. When discussing breathing exercises with a a. Help stop bleeding if any occurs
d. Coolness postoperative client, Nurse Hazel should include which b. Reduce the fluid trapped in the biliary ducts
33. Nurse Becky is caring for client who begins to of the following teaching? c. Position with greatest comfort
experience seizure while in bed. Which action should the a. Short frequent breaths d. Promote circulating blood volume
nurse implement to prevent aspiration? b. Exhale with mouth open 48. Tony has diagnosed with hepatitis A. The information
a. Position the client on the side with head flexed c. Exercise twice a day from the health history that is most likely linked to
forward d. Place hand on the abdomen and feel it rise hepatitis A is:
b. Elevate the head 41. Louie, with burns over 35% of the body, complains of a. Exposed with arsenic compounds at work
c. Use tongue depressor between teeth chilling. In promoting the client’s comfort, the nurse b. Working as local plumber
d. Loosen restrictive clothing should: c. Working at hemodialysis clinic
34. A client has undergone bone biopsy. Which nursing a. Maintain room humidity below 40% d. Dish washer in restaurants
action should the nurse provide after the procedure? b. Place top sheet on the client 49. Nurse Trish is aware that the laboratory test result
a. Administer analgesics via IM c. Limit the occurrence of drafts that most likely would indicate acute pancreatitis is an
b. Monitor vital signs d. Keep room temperature at 80 degrees elevated:
c. Monitor the site for bleeding, swelling and hematoma 42. Nurse Trish is aware that temporary heterograft (pig a. Serum bilirubin level
formation skin) is used to treat burns because this graft will: b. Serum amylase level
d. Keep area in neutral position a. Relieve pain and promote rapid epithelialization c. Potassium level
35. A client is suffering from low back pain. Which of the b. Be sutured in place for better adherence d. Sodium level
following exercises will strengthen the lower back c. Debride necrotic epithelium 50. Dr. Marquez orders serum electrolytes. To determine
muscle of the client? d. Concurrently used with topical antimicrobials the effect of persistent vomiting, Nurse Trish should be
a. Tennis 43. Mark has multiple abrasions and a laceration to the most concerned with monitoring the:
b. Basketball trunk and all four extremities says, “I can’t eat all this a. Chloride and sodium levels
c. Diving food”. The food that the nurse should suggest to be b. Phosphate and calcium levels
d. Swimming eaten first should be: c. Protein and magnesium levels
a. Meat loaf and coffee d. Sulfate and bicarbonate levels
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MEDICAL SURGICAL NURSING Part 2 c. Protects the client’s head from injury b. Hypertension d. Corneal reflex
d. Attempt to insert a tongue depressor between c. Ascites 22. The nurse is assessing a client with pleural effusion.
1. A client is scheduled for insertion of an inferior vena the client’s teeth d. Jaundice The nurse expect to find:
cava (IVC) filter. Nurse Patricia consults the physician 8. A client has undergone right pneumonectomy. When 15. A client is suspected to develop tetany after a a. Deviation of the trachea towards the involved
about withholding which regularly scheduled turning the client, the nurse should plan to position subtotal thyroidectomy. Which of the following side
medication on the day before the surgery? the client either: symptoms might indicate tetany? b. Reduced or absent of breath sounds at the
a. Potassium Chloride a. Right side-lying position or supine a. Tingling in the fingers base of the lung
b. Warfarin Sodium b. High fowlers b. Pain in hands and feet c. Moist crackles at the posterior of the lungs
c. Furosemide c. Right or left side lying position c. Tension on the suture lines d. Increased resonance with percussion of the
d. Docusate d. Low fowler’s position d. Bleeding on the back of the dressing involved area
2. A nurse is planning to assess the corneal reflex on 9. Nurse Jenny should caution a female client who is 16. A 58 year old woman has newly diagnosed with 23. A client admitted with newly diagnosed with
unconscious client. Which of the following is the sexually active in taking Isoniazid (INH) because the hypothyroidism. The nurse is aware that the signs Hodgkin’s disease. Which of the following would the
safest stimulus to touch the client’s cornea? drug has which of the following side effects? and symptoms of hypothyroidism include: nurse expect the client to report?
a. Cotton buds a. Prevents ovulation a. Diarrhea a. Lymph node pain
b. Sterile glove b. Has a mutagenic effect on ova b. Vomiting b. Weight gain
c. Sterile tongue depressor c. Decreases the effectiveness of oral c. Tachycardia c. Night sweats
d. Wisp of cotton contraceptives d. Weight gain d. Headache
3. A female client develops an infection at the catheter d. Increases the risk of vaginal infection 17. A client has undergone for an ileal conduit, the nurse 24. A client has suffered from fall and sustained a leg
insertion site. The nurse in charge uses the term 10. A client has undergone gastrectomy. Nurse Jovy is in charge should closely monitor the client for injury. Which appropriate question would the nurse
“iatrogenic” when describing the infection because it aware that the best position for the client is: occurrence of which of the following complications ask the client to help determine if the injury caused
resulted from: a. Left side lying related to pelvic surgery? fracture?
a. Client’s developmental level b. Low fowler’s a. Ascites a. “Is the pain sharp and continuous?”
b. Therapeutic procedure c. Prone b. Thrombophlebitis b. “Is the pain dull ache?”
c. Poor hygiene d. Supine c. Inguinal hernia c. “Does the discomfort feel like a cramp?”
d. Inadequate dietary patterns 11. During the initial postoperative period of the client’s d. Peritonitis d. “Does the pain feel like the muscle was
4. Nurse Carol is assessing a client with Parkinson’s stoma. The nurse evaluates which of the following 18. Dr. Marquez is about to defibrillate a client in stretched?”
disease. The nurse recognize bradykinesia when the observations should be reported immediately to the ventricular fibrillation and says in a loud voice 25. The Nurse is assessing the client’s casted extremity
client exhibits: physician? “clear”. What should be the action of the nurse? for signs of infection. Which of the following findings
a. Intentional tremor a. Stoma is dark red to purple a. Places conductive gel pads for defibrillation on is indicative of infection?
b. Paralysis of limbs b. Stoma is oozes a small amount of blood the client’s chest a. Edema
c. Muscle spasm c. Stoma is lightly edematous b. Turn off the mechanical ventilator b. Weak distal pulse
d. Lack of spontaneous movement d. Stoma does not expel stool c. Shuts off the client’s IV infusion c. Coolness of the skin
5. A client who suffered from automobile accident 12. Kate which has diagnosed with ulcerative colitis is d. Steps away from the bed and make sure all d. Presence of “hot spot” on the cast
complains of seeing frequent flashes of light. The following physician’s order for bed rest with others have done the same 26. Nurse Rhia is performing an otoscopic examination
nurse should expect: bathroom privileges. What is the rationale for this 19. A client has been diagnosed with glomerulonephritis on a female client with a suspected diagnosis of
a. Myopia activity restriction? complains of thirst. The nurse should offer: mastoiditis. Nurse Rhia would expect to note which
b. Detached retina a. Prevent injury a. Juice of the following if this disorder is present?
c. Glaucoma b. Promote rest and comfort b. Ginger ale a. Transparent tympanic membrane
d. Scleroderma c. Reduce intestinal peristalsis c. Milk shake b. Thick and immobile tympanic membrane
6. Kate with severe head injury is being monitored by the d. Conserve energy d. Hard candy c. Pearly colored tympanic membrane
nurse for increasing intracranial pressure (ICP). 13. Nurse KC should regularly assess the client’s ability to 20. A client with acute renal failure is aware that the d. Mobile tympanic membrane
Which finding should be most indicative sign of metabolize the total parenteral nutrition (TPN) most serious complication of this condition is: 27. Nurse Jocelyn is caring for a client with nasogastric
increasing intracranial pressure? solution adequately by monitoring the client for a. Constipation tube that is attached to low suction. Nurse Jocelyn
a. Intermittent tachycardia which of the following signs: b. Anemia assesses the client for symptoms of which acid-base
b. Polydipsia a. Hyperglycemia c. Infection disorder?
c. Tachypnea b. Hypoglycemia d. Platelet dysfunction a. Respiratory alkalosis
d. Increased restlessness c. Hypertension 21. Nurse Karen is caring for clients in the OR. The nurse b. Respiratory acidosis
7. A hospitalized client had a tonic-clonic seizure while d. Elevate blood urea nitrogen concentration is aware that the last physiologic function that the c. Metabolic acidosis
walking in the hall. During the seizure the nurse 14. A female client has an acute pancreatitis. Which of client loss during the induction of anesthesia is: d. Metabolic alkalosis
priority should be: the following signs and symptoms the nurse would a. Consciousness 28. A male adult client has undergone a lumbar puncture
a. Hold the clients arms and leg firmly expect to see? b. Gag reflex to obtain cerebrospinal fluid (CSF) for analysis.
b. Place the client immediately to soft surface a. Constipation c. Respiratory movement
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Which of the following values should be negative if b. Basketball 43. Mark has multiple abrasions and a laceration to the 50. Dr. Marquez orders serum electrolytes. To determine
the CSF is normal? c. Diving trunk and all four extremities says, “I can’t eat all this the effect of persistent vomiting, Nurse Trish should
a. Red blood cells d. Swimming food”. The food that the nurse should suggest to be be most concerned with monitoring the:
b. White blood cells 36. A client with peptic ulcer is being assessed by the eaten first should be: a. Chloride and sodium levels
c. Insulin nurse for gastrointestinal perforation. The nurse a. Meat loaf and coffee b. Phosphate and calcium levels
d. Protein should monitor for: b. Meat loaf and strawberries c. Protein and magnesium levels
29. A client is suspected of developing diabetes a. (+) guaiac stool test c. Tomato soup and apple pie d. Sulfate and bicarbonate levels
insipidus. Which of the following is the most b. Slow, strong pulse d. Tomato soup and buttered bread
effective assessment? c. Sudden, severe abdominal pain 44. Tony returns form surgery with permanent
a. Taking vital signs every 4 hours d. Increased bowel sounds colostomy. During the first 24 hours the colostomy
b. Monitoring blood glucose 37. A client has undergone surgery for retinal does not drain. The nurse should be aware that:
c. Assessing ABG values every other day detachment. Which of the following goal should be a. Proper functioning of nasogastric suction
d. Measuring urine output hourly prioritized? b. Presurgical decrease in fluid intake
30. A 58 year old client is suffering from acute phase of a. Prevent an increase intraocular pressure c. Absence of gastrointestinal motility
rheumatoid arthritis. Which of the following would b. Alleviate pain d. Intestinal edema following surgery
the nurse in charge identify as the lowest priority of c. Maintain darkened room 45. When teaching a client about the signs of colorectal
the plan of care? d. Promote low-sodium diet cancer, Nurse Trish stresses that the most common
a. Prevent joint deformity 38. A Client with glaucoma has been prescribed with complaint of persons with colorectal cancer is:
b. Maintaining usual ways of accomplishing task miotics. The nurse is aware that miotics is for: a. Abdominal pain
c. Relieving pain a. Constricting pupil b. Hemorrhoids
d. Preserving joint function b. Relaxing ciliary muscle c. Change in caliber of stools
31. Among the following, which client is autotransfusion c. Constricting intraocular vessel d. Change in bowel habits
possible? d. Paralyzing ciliary muscle 46. Louis develops peritonitis and sepsis after surgical
a. Client with AIDS 39. When suctioning an unconscious client, which repair of ruptures diverticulum. The nurse in charge
b. Client with ruptured bowel nursing intervention should the nurse prioritize in should expect an assessment of the client to reveal:
c. Client who is in danger of cardiac arrest maintaining cerebral perfusion? a. Tachycardia
d. Client with wound infection a. Administer diuretics b. Abdominal rigidity
32. Which of the following is not a sign of b. Administer analgesics c. Bradycardia
thromboembolism? c. Provide hygiene d. Increased bowel sounds
a. Edema d. Hyperoxygenate before and after suctioning 47. Immediately after liver biopsy, the client is placed on
b. Swelling 40. When discussing breathing exercises with a the right side, the nurse is aware that that this
c. Redness postoperative client, Nurse Hazel should include position should be maintained because it will:
d. Coolness which of the following teaching? a. Help stop bleeding if any occurs
33. Nurse Becky is caring for client who begins to a. Short frequent breaths b. Reduce the fluid trapped in the biliary ducts
experience seizure while in bed. Which action should b. Exhale with mouth open c. Position with greatest comfort
the nurse implement to prevent aspiration? c. Exercise twice a day d. Promote circulating blood volume
a. Position the client on the side with head d. Place hand on the abdomen and feel it rise 48. Tony has diagnosed with hepatitis A. The information
flexed forward 41. Louie, with burns over 35% of the body, complains of from the health history that is most likely linked to
b. Elevate the head chilling. In promoting the client’s comfort, the nurse hepatitis A is:
c. Use tongue depressor between teeth should: a. Exposed with arsenic compounds at work
d. Loosen restrictive clothing a. Maintain room humidity below 40% b. Working as local plumber
34. A client has undergone bone biopsy. Which nursing b. Place top sheet on the client c. Working at hemodialysis clinic
action should the nurse provide after the procedure? c. Limit the occurrence of drafts d. Dish washer in restaurants
a. Administer analgesics via IM d. Keep room temperature at 80 degrees 49. Nurse Trish is aware that the laboratory test result
b. Monitor vital signs 42. Nurse Trish is aware that temporary heterograft (pig that most likely would indicate acute pancreatitis is
c. Monitor the site for bleeding, swelling and skin) is used to treat burns because this graft will: an elevated:
hematoma formation a. Relieve pain and promote rapid a. Serum bilirubin level
d. Keep area in neutral position epithelialization b. Serum amylase level
35. A client is suffering from low back pain. Which of the b. Be sutured in place for better adherence c. Potassium level
following exercises will strengthen the lower back c. Debride necrotic epithelium d. Sodium level
muscle of the client? d. Concurrently used with topical antimicrobials
a. Tennis
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ANSWERS and RATIONALES for MEDICAL SURGICAL manipulation that can interfere with circulation and 34. C. Nursing care after bone biopsy includes close
NURSING Part 2 promote venous stasis. monitoring of the punctured site for bleeding,
18. D. For the safety of all personnel, if the defibrillator swelling and hematoma formation.
1. B. In preoperative period, the nurse should consult paddles are being discharged, all personnel must 35. D. Walking and swimming are very helpful in
with the physician about withholding Warfarin stand back and be clear of all the contact with the strengthening back muscles for the client suffering
Sodium to avoid occurrence of hemorrhage. client or the client’s bed. from lower back pain.
2. D. A client who is unconscious is at greater risk for 19. D. Hard candy will relieve thirst and increase 36. C. Sudden, severe abdominal pain is the most
corneal abrasion. For this reason, the safest way to carbohydrates but does not supply extra fluid. indicative sign of perforation. When perforation of
test the cornel reflex is by touching the cornea 20. C. Infection is responsible for one third of the an ulcer occurs, the nurse maybe unable to hear
lightly with a wisp of cotton. traumatic or surgically induced death of clients with bowel sounds at all.
3. B. Iatrogenic infection is caused by the heath care renal failure as well as medical induced acute renal 37. A. After surgery to correct a detached retina,
provider or is induced inadvertently by medical failure (ARF) prevention of increased intraocular pressure is the
treatment or procedures. 21. C. There is no respiratory movement in stage 4 of priority goal.
4. D. Bradykinesia is slowing down from the initiation anesthesia, prior to this stage, respiration is 38. A. Miotic agent constricts the pupil and contracts
and execution of movement. depressed but present. ciliary muscle. These effects widen the filtration
5. B. This symptom is caused by stimulation of retinal 22. B. Compression of the lung by fluid that accumulates angle and permit increased out flow of aqueous
cells by ocular movement. at the base of the lungs reduces expansion and air humor.
6. D. Restlessness indicates a lack of oxygen to the brain exchange. 39. D. It is a priority to hyperoxygenate the client before
stem which impairs the reticular activating system. 23. C. Assessment of a client with Hodgkin’s disease and after suctioning to prevent hypoxia and to
7. C. Rhythmic contraction and relaxation associated most often reveals enlarged, painless lymph node, maintain cerebral perfusion.
with tonic-clonic seizure can cause repeated banging fever, malaise and night sweats. 40. D. Abdominal breathing improves lungs expansion
of head. 24. A. Fractured pain is generally described as sharp, 41. C. A Client with burns is very sensitive to
8. A. Right side lying position or supine position permits continuous, and increasing in frequency. temperature changes because heat is loss in the
ventilation of the remaining lung and prevent fluid 25. D. Signs and symptoms of infection under a casted burn areas.
from draining into sutured bronchial stump. area include odor or purulent drainage and the 42. A. The graft covers the nerve endings, which reduces
9. C. Isoniazid (INH) interferes in the effectiveness of oral presence of “hot spot” which are areas on the cast pain and provides framework for granulation
contraceptives and clients of childbearing age should that are warmer than the others. 43. B. Meat provides proteins and the fruit proteins
be counseled to use an alternative form of birth 26. B. Otoscopic examnation in a client with mastoiditis vitamin C that both promote wound healing.
control while taking this drug. reveals a dull, red, thick and immobile tymphanic 44. C. This is primarily caused by the trauma of intestinal
10. B. A client who has had abdominal surgery is best membrane with or without perforation. manipulation and the depressive effects anesthetics
placed in a low fowler’s position. This relaxes 27. D. Loss of gastric fluid via nasogastric suction or and analgesics.
abdominal muscles and provides maximum vomiting causes metabolic alkalosis because of the 45. D. Constipation, diarrhea, and/or constipation
respiratory and cardiovascular function. loss of hydrochloric acid which is a potent acid in the alternating with diarrhea are the most common
11. A. Dark red to purple stoma indicates inadequate body. symptoms of colorectal cancer.
blood supply. 28. A. The adult with normal cerebrospinal fluid has no 46. B. With increased intraabdominal pressure, the
12. C. The rationale for activity restriction is to help red blood cells. abdominal wall will become tender and rigid.
reduce the hypermotility of the colon. 29. D. Measuring the urine output to detect excess 47. A. Pressure applied in the puncture site indicates
13. A. During Total Parenteral Nutrition (TPN) amount and checking the specific gravity of urine that a biliary vessel was puncture which is a common
administration, the client should be monitored samples to determine urine concentration are complication after liver biopsy.
regularly for hyperglycemia. appropriate measures to determine the onset of 48. B. Hepatitis A is primarily spread via fecal-oral route.
14. D. Jaundice may be present in acute pancreatitis diabetes insipidus. Sewage polluted water may harbor the virus.
owing to obstruction of the biliary duct. 30. B. The nurse should focus more on developing less 49. B. Amylase concentration is high in the pancreas and
15. A. Tetany may occur after thyroidectomy if the stressful ways of accomplishing routine task. is elevated in the serum when the pancreas becomes
parathyroid glands are accidentally injured or 31. C. Autotransfusion is acceptable for the client who is acutely inflamed and also it distinguishes
removed. in danger of cardiac arrest. pancreatitis from other acute abdominal problems.
16. D. Typical signs of hypothyroidism includes weight 32. D. The client with thromboembolism does not have 50. A. Sodium, which is concerned with the regulation of
gain, fatigue, decreased energy, apathy, brittle nails, coolness. extracellular fluid volume, it is lost with vomiting.
dry skin, cold intolerance, constipation and 33. A. Positioning the client on one side with head flexed Chloride, which balances cations in the extracellular
numbness. forward allows the tongue to fall forward and compartments, is also lost with vomiting, because
17. B. After a pelvic surgery, there is an increased chance facilitates drainage secretions therefore prevents sodium and chloride are parallel electrolytes,
of thrombophlebitits owing to the pelvic aspiration. hyponatremia will accompany.
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MEDICAL SURGICAL NURSING Part 3 7. A client has undergone with penile implant. After 24 14. Nurse Josie should instruct the client to eat which of 21. Which of the following signs and symptoms would
hrs of surgery, the client’s scrotum was edematous the following foods to obtain the best supply of Nurse Maureen include in teaching plan as an early
1. Marco who was diagnosed with brain tumor was and painful. The nurse should: Vitamin B12? manifestation of laryngeal cancer?
scheduled for craniotomy. In preventing the a. Assist the client with sitz bath a. dairy products a. Stomatitis
development of cerebral edema after surgery, the b. Apply war soaks in the scrotum b. vegetables b. Airway obstruction
nurse should expect the use of: c. Elevate the scrotum using a soft support c. Grains c. Hoarseness
a. Diuretics d. Prepare for a possible incision and drainage. d. Broccoli d. Dysphagia
b. Antihypertensive 8. Nurse hazel receives emergency laboratory results for 15. Karen has been diagnosed with aplastic anemia. The 22. Karina a client with myasthenia gravis is to receive
c. Steroids a client with chest pain and immediately informs the nurse monitors for changes in which of the following immunosuppressive therapy. The nurse understands
d. Anticonvulsants physician. An increased myoglobin level suggests physiologic functions? that this therapy is effective because it:
2. Halfway through the administration of blood, the which of the following? a. Bowel function a. Promotes the removal of antibodies that
female client complains of lumbar pain. After a. Liver disease b. Peripheral sensation impair the transmission of impulses
stopping the infusion Nurse Hazel should: b. Myocardial damage c. Bleeding tendencies b. Stimulates the production of acetylcholine at
a. Increase the flow of normal saline c. Hypertension d. Intake and out put the neuromuscular junction.
b. Assess the pain further d. Cancer 16. Lydia is scheduled for elective splenectomy. Before c. Decreases the production of autoantibodies
c. Notify the blood bank 9. Nurse Maureen would expect the a client with mitral the clients goes to surgery, the nurse in charge final that attack the acetylcholine receptors.
d. Obtain vital signs. stenosis would demonstrate symptoms associated assessment would be: d. Inhibits the breakdown of acetylcholine at the
3. Nurse Maureen knows that the positive diagnosis for with congestion in the: a. signed consent neuromuscular junction.
HIV infection is made based on which of the a. Right atrium b. vital signs 23. A female client is receiving IV Mannitol. An
following: b. Superior vena cava c. name band assessment specific to safe administration of the
a. A history of high risk sexual behaviors. c. Aorta d. empty bladder said drug is:
b. Positive ELISA and western blot tests d. Pulmonary 17. What is the peak age range in acquiring acute a. Vital signs q4h
c. Identification of an associated opportunistic 10. A client has been diagnosed with hypertension. The lymphocytic leukemia (ALL)? b. Weighing daily
infection nurse priority nursing diagnosis would be: a. 4 to 12 years. c. Urine output hourly
d. Evidence of extreme weight loss and high a. Ineffective health maintenance b. 20 to 30 years d. Level of consciousness q4h
fever b. Impaired skin integrity c. 40 to 50 years 24. Patricia a 20 year old college student with diabetes
4. Nurse Maureen is aware that a client who has been c. Deficient fluid volume d. 60 60 70 years mellitus requests additional information about the
diagnosed with chronic renal failure recognizes an d. Pain 18. Marie with acute lymphocytic leukemia suffers from advantages of using a pen like insulin delivery
adequate amount of high-biologic-value protein 11. Nurse Hazel teaches the client with angina about nausea and headache. These clinical manifestations devices. The nurse explains that the advantages of
when the food the client selected from the menu common expected side effects of nitroglycerin may indicate all of the following except these devices over syringes includes:
was: including: a. effects of radiation a. Accurate dose delivery
a. Raw carrots a. high blood pressure b. chemotherapy side effects b. Shorter injection time
b. Apple juice b. stomach cramps c. meningeal irritation c. Lower cost with reusable insulin cartridges
c. Whole wheat bread c. headache d. gastric distension d. Use of smaller gauge needle.
d. Cottage cheese d. shortness of breath 19. A client has been diagnosed with Disseminated 25. A male client’s left tibia was fractured in an
5. Kenneth who has diagnosed with uremic syndrome 12. The following are lipid abnormalities. Which of the Intravascular Coagulation (DIC). Which of the automobile accident, and a cast is applied. To assess
has the potential to develop complications. Which following is a risk factor for the development of following is contraindicated with the client? for damage to major blood vessels from the fracture
among the following complications should the nurse atherosclerosis and PVD? a. Administering Heparin tibia, the nurse in charge should monitor the client
anticipates: a. High levels of low density lipid (LDL) b. Administering Coumadin for:
a. Flapping hand tremors cholesterol c. Treating the underlying cause a. Swelling of the left thigh
b. An elevated hematocrit level b. High levels of high density lipid (HDL) d. Replacing depleted blood products b. Increased skin temperature of the foot
c. Hypotension cholesterol 20. Which of the following findings is the best indication c. Prolonged reperfusion of the toes after
d. Hypokalemia c. Low concentration triglycerides that fluid replacement for the client with blanching
6. A client is admitted to the hospital with benign d. Low levels of LDL cholesterol. hypovolemic shock is adequate? d. Increased blood pressure
prostatic hyperplasia, the nurse most relevant 13. Which of the following represents a significant risk a. Urine output greater than 30ml/hr 26. After a long leg cast is removed, the male client
assessment would be: immediately after surgery for repair of aortic b. Respiratory rate of 21 breaths/minute should:
a. Flank pain radiating in the groin aneurysm? c. Diastolic blood pressure greater than 90 a. Cleanse the leg by scrubbing with a brisk
b. Distention of the lower abdomen a. Potential wound infection mmhg motion
c. Perineal edema b. Potential ineffective coping d. Systolic blood pressure greater than 110 b. Put leg through full range of motion twice
d. Urethral discharge c. Potential electrolyte balance mmhg daily
d. Potential alteration in renal perfusion c. Report any discomfort or stiffness to the
physician
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d. Elevate the leg when sitting for long periods of cause of tonic clonic seizures in adults more the 20 40. A 65 year old female is experiencing flare up of d. elder abuse
time. years? pruritus. Which of the client’s action could aggravate 48. Nurse Anna is aware that early adaptation of client
27. While performing a physical assessment of a male a. Electrolyte imbalance the cause of flare ups? with renal carcinoma is:
client with gout of the great toe, Nurse Vivian should b. Head trauma a. Sleeping in cool and humidified environment a. Nausea and vomiting
assess for additional tophi (urate deposits) on the: c. Epilepsy b. Daily baths with fragrant soap b. flank pain
a. Buttocks d. Congenital defect c. Using clothes made from 100% cotton c. weight gain
b. Ears 34. What is the priority nursing assessment in the first 24 d. Increasing fluid intake d. intermittent hematuria
c. Face hours after admission of the client with thrombotic 41. Atropine sulfate (Atropine) is contraindicated in all 49. A male client with tuberculosis asks Nurse Brian how
d. Abdomen CVA? but one of the following client? long the chemotherapy must be continued. Nurse
28. Nurse Katrina would recognize that the a. Pupil size and papillary response a. A client with high blood Brian’s accurate reply would be:
demonstration of crutch walking with tripod gait was b. cholesterol level b. A client with bowel obstruction a. 1 to 3 weeks
understood when the client places weight on the: c. Echocardiogram c. A client with glaucoma b. 6 to 12 months
a. Palms of the hands and axillary regions d. Bowel sounds d. A client with U.T.I c. 3 to 5 months
b. Palms of the hand 35. Nurse Linda is preparing a client with multiple 42. Among the following clients, which among them is d. 3 years and more
c. Axillary regions sclerosis for discharge from the hospital to home. high risk for potential hazards from the surgical 50. A client has undergone laryngectomy. The immediate
d. Feet, which are set apart Which of the following instruction is most experience? nursing priority would be:
29. Mang Jose with rheumatoid arthritis states, “the only appropriate? a. 67-year-old client a. Keep trachea free of secretions
time I am without pain is when I lie in bed perfectly a. “Practice using the mechanical aids that you b. 49-year-old client b. Monitor for signs of infection
still”. During the convalescent stage, the nurse in will need when future disabilities arise”. c. 33-year-old client c. Provide emotional support
charge with Mang Jose should encourage: b. “Follow good health habits to change the d. 15-year-old client d. Promote means of communication
a. Active joint flexion and extension course of the disease”. 43. Nurse Jon assesses vital signs on a client undergone
b. Continued immobility until pain subsides c. “Keep active, use stress reduction strategies, epidural anesthesia. Which of the following would
c. Range of motion exercises twice daily and avoid fatigue. the nurse assess next?
d. Flexion exercises three times daily d. “You will need to accept the necessity for a a. Headache
30. A male client has undergone spinal surgery, the quiet and inactive lifestyle”. b. Bladder distension
nurse should: 36. The nurse is aware the early indicator of hypoxia in c. Dizziness
a. Observe the client’s bowel movement and the unconscious client is: d. Ability to move legs
voiding patterns a. Cyanosis 44. Nurse Katrina should anticipate that all of the
b. Log-roll the client to prone position b. Increased respirations following drugs may be used in the attempt to
c. Assess the client’s feet for sensation and c. Hypertension control the symptoms of Meniere’s disease except:
circulation d. Restlessness a. Antiemetics
d. Encourage client to drink plenty of fluids 37. A client is experiencing spinal shock. Nurse Myrna b. Diuretics
31. Marina with acute renal failure moves into the should expect the function of the bladder to be c. Antihistamines
diuretic phase after one week of therapy. During this which of the following? d. Glucocorticoids
phase the client must be assessed for signs of a. Normal 45. Which of the following complications associated with
developing: b. Atonic tracheostomy tube?
a. Hypovolemia c. Spastic a. Increased cardiac output
b. renal failure d. Uncontrolled b. Acute respiratory distress syndrome (ARDS)
c. metabolic acidosis 38. Which of the following stage the carcinogen is c. Increased blood pressure
d. hyperkalemia irreversible? d. Damage to laryngeal nerves
32. Nurse Judith obtains a specimen of clear nasal a. Progression stage 46. Nurse Faith should recognize that fluid shift in an
drainage from a client with a head injury. Which of b. Initiation stage client with burn injury results from increase in the:
the following tests differentiates mucus from c. Regression stage a. Total volume of circulating whole blood
cerebrospinal fluid (CSF)? d. Promotion stage b. Total volume of intravascular plasma
a. Protein 39. Among the following components thorough pain c. Permeability of capillary walls
b. Specific gravity assessment, which is the most significant? d. Permeability of kidney tubules
c. Glucose a. Effect 47. An 83-year-old woman has several ecchymotic areas
d. Microorganism b. Cause on her right arm. The bruises are probably caused
33. A 22 year old client suffered from his first tonic- c. Causing factors by:
clonic seizure. Upon awakening the client asks the d. Intensity a. increased capillary fragility and permeability
nurse, “What caused me to have a seizure? Which of b. increased blood supply to the skin
the following would the nurse include in the primary c. self inflicted injury
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ANSWERS and RATIONALES for MEDICAL SURGICAL 15. C. Aplastic anemia decreases the bone marrow 29. A. Active exercises, alternating extension, flexion, 45. D. Tracheostomy tube has several potential
NURSING Part 3 production of RBC’s, white blood cells, and platelets. abduction, and adduction, mobilize exudates in the complications including bleeding, infection and
The client is at risk for bruising and bleeding joints relieves stiffness and pain. laryngeal nerve damage.
1. C. Glucocorticoids (steroids) are used for their anti- tendencies. 30. C. Alteration in sensation and circulation indicates 46. C. In burn, the capillaries and small vessels dilate,
inflammatory action, which decreases the 16. B. An elective procedure is scheduled in advance so damage to the spinal cord, if these occurs notify and cell damage cause the release of a histamine-
development of edema. that all preparations can be completed ahead of physician immediately. like substance. The substance causes the capillary
2. A. The blood must be stopped at once, and then time. The vital signs are the final check that must be 31. A. In the diuretic phase fluid retained during the walls to become more permeable and significant
normal saline should be infused to keep the line completed before the client leaves the room so that oliguric phase is excreted and may reach 3 to 5 liters quantities of fluid are lost.
patent and maintain blood volume. continuity of care and assessment is provided for. daily, hypovolemia may occur and fluids should be 47. A. Aging process involves increased capillary fragility
3. B. These tests confirm the presence of HIV antibodies 17. A. The peak incidence of Acute Lymphocytic replaced. and permeability. Older adults have a decreased
that occur in response to the presence of the human Leukemia (ALL) is 4 years of age. It is uncommon 32. C. The constituents of CSF are similar to those of amount of subcutaneous fat and cause an increased
immunodeficiency virus (HIV). after 15 years of age. blood plasma. An examination for glucose content is incidence of bruise like lesions caused by collection
4. D. One cup of cottage cheese contains approximately 18. D. Acute Lymphocytic Leukemia (ALL) does not cause done to determine whether a body fluid is a mucus of extravascular blood in loosely structured dermis.
225 calories, 27 g of protein, 9 g of fat, 30 mg gastric distention. It does invade the central nervous or a CSF. A CSF normally contains glucose. 48. D. Intermittent pain is the classic sign of renal
cholesterol, and 6 g of carbohydrate. Proteins of system, and clients experience headaches and 33. B. Trauma is one of the primary cause of brain carcinoma. It is primarily due to capillary erosion by
high biologic value (HBV) contain optimal levels of vomiting from meningeal irritation. damage and seizure activity in adults. Other the cancerous growth.
amino acids essential for life. 19. B. Disseminated Intravascular Coagulation (DIC) has common causes of seizure activity in adults include 49. B. Tubercle bacillus is a drug resistant organism and
5. A. Elevation of uremic waste products causes irritation not been found to respond to oral anticoagulants neoplasms, withdrawal from drugs and alcohol, and takes a long time to be eradicated. Usually a
of the nerves, resulting in flapping hand tremors. such as Coumadin. vascular disease. combination of three drugs is used for minimum of 6
6. B. This indicates that the bladder is distended with 20. A. Urine output provides the most sensitive 34. A. It is crucial to monitor the pupil size and papillary months and at least six months beyond culture
urine, therefore palpable. indication of the client’s response to therapy for response to indicate changes around the cranial conversion.
7. C. Elevation increases lymphatic drainage, reducing hypovolemic shock. Urine output should be nerves. 50. A. Patent airway is the most priority; therefore
edema and pain. consistently greater than 30 to 35 mL/hr. 35. C. The nurse most positive approach is to encourage removal of secretions is necessary.
8. B. Detection of myoglobin is a diagnostic tool to 21. C. Early warning signs of laryngeal cancer can vary the client with multiple sclerosis to stay active, use
determine whether myocardial damage has depending on tumor location. Hoarseness lasting 2 stress reduction techniques and avoid fatigue
occurred. weeks should be evaluated because it is one of the because it is important to support the immune
9. D. When mitral stenosis is present, the left atrium has most common warning signs. system while remaining active.
difficulty emptying its contents into the left ventricle 22. C. Steroids decrease the body’s immune response 36. D. Restlessness is an early indicator of hypoxia. The
because there is no valve to prevent back ward flow thus decreasing the production of antibodies that nurse should suspect hypoxia in unconscious client
into the pulmonary vein, the pulmonary circulation is attack the acetylcholine receptors at the who suddenly becomes restless.
under pressure. neuromuscular junction 37. B. In spinal shock, the bladder becomes completely
10. A. Managing hypertension is the priority for the 23. C. The osmotic diuretic mannitol is contraindicated in atonic and will continue to fill unless the client is
client with hypertension. Clients with hypertension the presence of inadequate renal function or heart catheterized.
frequently do not experience pain, deficient volume, failure because it increases the intravascular volume 38. A. Progression stage is the change of tumor from the
or impaired skin integrity. It is the asymptomatic that must be filtered and excreted by the kidney. preneoplastic state or low degree of malignancy to a
nature of hypertension that makes it so difficult to 24. A. These devices are more accurate because they are fast growing tumor that cannot be reversed.
treat. easily to used and have improved adherence in 39. D. Intensity is the major indicative of severity of pain
11. C. Because of its widespread vasodilating effects, insulin regimens by young people because the and it is important for the evaluation of the
nitroglycerin often produces side effects such as medication can be administered discreetly. treatment.
headache, hypotension and dizziness. 25. C. Damage to blood vessels may decrease the 40. B. The use of fragrant soap is very drying to skin
12. A. An increased in LDL cholesterol concentration has circulatory perfusion of the toes, this would indicate hence causing the pruritus.
been documented at risk factor for the development the lack of blood supply to the extremity. 41. C. Atropine sulfate is contraindicated with glaucoma
of atherosclerosis. LDL cholesterol is not broken 26. D. Elevation will help control the edema that usually patients because it increases intraocular pressure.
down into the liver but is deposited into the wall of occurs. 42. A. A 67 year old client is greater risk because the
the blood vessels. 27. B. Uric acid has a low solubility, it tends to older adult client is more likely to have a less-
13. D. There is a potential alteration in renal perfusion precipitate and form deposits at various sites where effective immune system.
manifested by decreased urine output. The altered blood flow is least active, including cartilaginous 43. B. The last area to return sensation is in the perineal
renal perfusion may be related to renal artery tissue such as the ears. area, and the nurse in charge should monitor the
embolism, prolonged hypotension, or prolonged 28. B. The palms should bear the client’s weight to avoid client for distended bladder.
aortic cross-clamping during the surgery. damage to the nerves in the axilla. 44. D. Glucocorticoids play no significant role in disease
14. A. Good source of vitamin B12 are dairy products treatment.
and meats.
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PSYCHIATRIC NURSING Part 1 b. Avoiding relationship a. Cardiac dysrhythmias resulting to c. Shame

c. Showing interest in solitary activities cardiac arrest d. Remorsefulness
1. Marco approached Nurse Trish asking for advice d. Inability to make choices and decision b. Glucose intolerance resulting in 20. Which of the following approaches would be
on how to deal with his alcohol addiction. Nurse without advise protracted hypoglycemia most appropriate to use with a client suffering from
Trish should tell the client that the only effective 8. A male client is diagnosed with schizotypal c. Endocrine imbalance causing cold narcissistic personality disorder when discrepancies
treatment for alcoholism is: personality disorder. Which signs would this client amenorrhea exist between what the client states and what
a. Psychotherapy exhibit during social situation? d. Decreased metabolism causing cold actually exist?
b. Alcoholics anonymous (A.A.) a. Paranoid thoughts intolerance a. Rationalization
c. Total abstinence b. Emotional affect 15. Nurse Anna can minimize agitation in a b. Supportive confrontation
d. Aversion Therapy c. Independence need disturbed client by? c. Limit setting
2. Nurse Hazel is caring for a male client who d. Aggressive behavior a. Increasing stimulation d. Consistency
experience false sensory perceptions with no basis in 9. Nurse Claire is caring for a client diagnosed with b. limiting unnecessary interaction 21. Cely is experiencing alcohol withdrawal exhibits
reality. This perception is known as: bulimia. The most appropriate initial goal for a client c. increasing appropriate sensory tremors, diaphoresis and hyperactivity. Blood
a. Hallucinations diagnosed with bulimia is? perception pressure is 190/87 mmhg and pulse is 92 bpm.
b. Delusions a. Encourage to avoid foods d. ensuring constant client and staff Which of the medications would the nurse expect to
c. Loose associations b. Identify anxiety causing situations contact administer?
d. Neologisms c. Eat only three meals a day 16. A 39 year old mother with obsessive-compulsive a. Naloxone (Narcan)
3. Nurse Monet is caring for a female client who d. Avoid shopping plenty of groceries disorder has become immobilized by her elaborate b. Benzlropine (Cogentin)
has suicidal tendency. When accompanying the 10. Nurse Tony was caring for a 41 year old female hand washing and walking rituals. Nurse Trish c. Lorazepam (Ativan)
client to the restroom, Nurse Monet should… client. Which behavior by the client indicates adult recognizes that the basis of O.C. disorder is often: d. Haloperidol (Haldol)
a. Give her privacy cognitive development? a. Problems with being too conscientious 22. Which of the following foods would the nurse
b. Allow her to urinate a. Generates new levels of awareness b. Problems with anger and remorse Trish eliminate from the diet of a client in alcohol
c. Open the window and allow her to get b. Assumes responsibility for her actions c. Feelings of guilt and inadequacy withdrawal?
some fresh air c. Has maximum ability to solve problems d. Feeling of unworthiness and a. Milk
d. Observe her and learn new skills hopelessness b. Orange Juice
4. Nurse Maureen is developing a plan of care for a d. Her perception are based on reality 17. Mario is complaining to other clients about not c. Soda
female client with anorexia nervosa. Which action 11. A neuromuscular blocking agent is administered being allowed by staff to keep food in his room. d. Regular Coffee
should the nurse include in the plan? to a client before ECT therapy. The Nurse should Which of the following interventions would be most 23. Which of the following would Nurse Hazel
a. Provide privacy during meals carefully observe the client for? appropriate? expect to assess for a client who is exhibiting late
b. Set-up a strict eating plan for the client a. Respiratory difficulties a. Allowing a snack to be kept in his room signs of heroin withdrawal?
c. Encourage client to exercise to reduce b. Nausea and vomiting b. Reprimanding the client a. Yawning & diaphoresis
anxiety c. Dizziness c. Ignoring the clients behavior b. Restlessness & Irritability
d. Restrict visits with the family d. Seizures d. Setting limits on the behavior c. Constipation & steatorrhea
5. A client is experiencing anxiety attack. The most 12. A 75 year old client is admitted to the hospital 18. Conney with borderline personality disorder who d. Vomiting and Diarrhea
appropriate nursing intervention should include? with the diagnosis of dementia of the Alzheimer’s is to be discharge soon threatens to “do something” 24. To establish open and trusting relationship with
a. Turning on the television type and depression. The symptom that is unrelated to herself if discharged. Which of the following a female client who has been hospitalized with
b. Leaving the client alone to depression would be? actions by the nurse would be most important? severe anxiety, the nurse in charge should?
c. Staying with the client and speaking in a. Apathetic response to the environment a. Ask a family member to stay with the a. Encourage the staff to have frequent
short sentences b. “I don’t know” answer to questions client at home temporarily interaction with the client
d. Ask the client to play with other clients c. Shallow of labile effect b. Discuss the meaning of the client’s b. Share an activity with the client
6. A female client is admitted with a diagnosis of d. Neglect of personal hygiene statement with her c. Give client feedback about behavior
delusions of GRANDEUR. This diagnosis reflects a 13. Nurse Trish is working in a mental health facility; c. Request an immediate extension for the d. Respect client’s need for personal space
belief that one is: the nurse priority nursing intervention for a newly client 25. Nurse Monette recognizes that the focus of
a. Being Killed admitted client with bulimia nervosa would be to? d. Ignore the clients statement because it’s environmental (MILIEU) therapy is to:
b. Highly famous and important a. Teach client to measure I & O a sign of manipulation a. Manipulate the environment to bring
c. Responsible for evil world b. Involve client in planning daily meal 19. Joey a client with antisocial personality disorder about positive changes in behavior
d. Connected to client unrelated to oneself c. Observe client during meals belches loudly. A staff member asks Joey, “Do you b. Allow the client’s freedom to determine
7. A 20 year old client was diagnosed with d. Monitor client continuously know why people find you repulsive?” this whether or not they will be involved in activities
dependent personality disorder. Which behavior is 14. Nurse Patricia is aware that the major health statement most likely would elicit which of the c. Role play life events to meet individual
not most likely to be evidence of ineffective complication associated with intractable anorexia following client reaction? needs
individual coping? nervosa would be? a. Depensiveness d. Use natural remedies rather than drugs
a. Recurrent self-destructive behavior b. Embarrassment to control behavior
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26. Nurse Trish would expect a child with a diagnosis b. Depression and a blunted affect when d. Touching the client provide assurance a. Ask the client direct questions to
of reactive attachment disorder to: discussing the traumatic situation 39. When planning care for a female client using encourage talking
a. Have more positive relation with the c. Lack of interest in family & others ritualistic behavior, Nurse Gina must recognize that b. Rake the client into the dayroom to be
father than the mother d. Re-experiencing the trauma in dreams or the ritual: with other clients
b. Cling to mother & cry on separation flashback a. Helps the client focus on the inability to c. Sit beside the client in silence and
c. Be able to develop only superficial 33. Nurse Benjie is communicating with a male client deal with reality occasionally ask open-ended question
relation with the others with substance-induced persisting dementia; the b. Helps the client control the anxiety d. Leave the client alone and continue with
d. Have been physically abuse client cannot remember facts and fills in the gaps c. Is under the client’s conscious control providing care to the other clients
27. When teaching parents about childhood with imaginary information. Nurse Benjie is aware d. Is used by the client primarily for 45. Nurse Tina is caring for a client with delirium and
depression Nurse Trina should say? that this is typical of? secondary gains states that “look at the spiders on the wall”. What
a. It may appear acting out behavior a. Flight of ideas 40. A 32 year old male graduate student, who has should the nurse respond to the client?
b. Does not respond to conventional b. Associative looseness become increasingly withdrawn and neglectful of his a. “You’re having hallucination, there are
treatment c. Confabulation work and personal hygiene, is brought to the no spiders in this room at all”
c. Is short in duration & resolves easily d. Concretism psychiatric hospital by his parents. After detailed b. “I can see the spiders on the wall, but
d. Looks almost identical to adult 34. Nurse Joey is aware that the signs & symptoms assessment, a diagnosis of schizophrenia is made. It they are not going to hurt you”
depression that would be most specific for diagnosis anorexia is unlikely that the client will demonstrate: c. “Would you like me to kill the spiders”
28. Nurse Perry is aware that language development are? a. Low self esteem d. “I know you are frightened, but I do not
in autistic child resembles: a. Excessive weight loss, amenorrhea & b. Concrete thinking see spiders on the wall”
a. Scanning speech abdominal distension c. Effective self boundaries 46. Nurse Jonel is providing information to a
b. Speech lag b. Slow pulse, 10% weight loss & alopecia d. Weak ego community group about violence in the family.
c. Shuttering c. Compulsive behavior, excessive fears & 41. A 23 year old client has been admitted with a Which statement by a group member would indicate
d. Echolalia nausea diagnosis of schizophrenia says to the nurse “Yes, its a need to provide additional information?
29. A 60 year old female client who lives alone tells d. Excessive activity, memory lapses & an march, March is little woman”. That’s literal you a. “Abuse occurs more in low-income
the nurse at the community health center “I really increased pulse know”. These statement illustrate: families”
don’t need anyone to talk to”. The TV is my best 35. A characteristic that would suggest to Nurse a. Neologisms b. “Abuser Are often jealous or self-
friend. The nurse recognizes that the client is using Anne that an adolescent may have bulimia would be: b. Echolalia centered”
the defense mechanism known as? a. Frequent regurgitation & re-swallowing c. Flight of ideas c. “Abuser use fear and intimidation”
a. Displacement of food d. Loosening of association d. “Abuser usually have poor self-esteem”
b. Projection b. Previous history of gastritis 42. A long term goal for a paranoid male client who 47. During electroconvulsive therapy (ECT) the client
c. Sublimation c. Badly stained teeth has unjustifiably accused his wife of having many receives oxygen by mask via positive pressure
d. Denial d. Positive body image extramarital affairs would be to help the client ventilation. The nurse assisting with this procedure
30. When working with a male client suffering 36. Nurse Monette is aware that extremely develop: knows that positive pressure ventilation is necessary
phobia about black cats, Nurse Trish should depressed clients seem to do best in settings where a. Insight into his behavior because?
anticipate that a problem for this client would be? they have: b. Better self control a. Anesthesia is administered during the
a. Anxiety when discussing phobia a. Multiple stimuli c. Feeling of self worth procedure
b. Anger toward the feared object b. Routine Activities d. Faith in his wife b. Decrease oxygen to the brain increases
c. Denying that the phobia exist c. Minimal decision making 43. A male client who is experiencing disordered confusion and disorientation
d. Distortion of reality when completing d. Varied Activities thinking about food being poisoned is admitted to c. Grand mal seizure activity depresses
daily routines 37. To further assess a client’s suicidal potential. the mental health unit. The nurse uses which respirations
31. Linda is pacing the floor and appears extremely Nurse Katrina should be especially alert to the client communication technique to encourage the client to d. Muscle relaxations given to prevent
anxious. The duty nurse approaches in an attempt to expression of: eat dinner? injury during seizure activity depress respirations.
alleviate Linda’s anxiety. The most therapeutic a. Frustration & fear of death a. Focusing on self-disclosure of own food 48. When planning the discharge of a client with
question by the nurse would be? b. Anger & resentment preference chronic anxiety, Nurse Chris evaluates achievement
a. Would you like to watch TV? c. Anxiety & loneliness b. Using open ended question and silence of the discharge maintenance goals. Which goal
b. Would you like me to talk with you? d. Helplessness & hopelessness c. Offering opinion about the need to eat would be most appropriately having been included
c. Are you feeling upset now? 38. A nursing care plan for a male client with bipolar d. Verbalizing reasons that the client may in the plan of care requiring evaluation?
d. Ignore the client I disorder should include: not choose to eat a. The client eliminates all anxiety from
32. Nurse Penny is aware that the symptoms that a. Providing a structured environment 44. Nurse Nina is assigned to care for a client daily situations
distinguish post traumatic stress disorder from other b. Designing activities that will require the diagnosed with Catatonic Stupor. When Nurse Nina b. The client ignores feelings of anxiety
anxiety disorder would be: client to maintain contact with reality enters the client’s room, the client is found lying on c. The client identifies anxiety producing
a. Avoidance of situation & certain c. Engaging the client in conversing about the bed with a body pulled into a fetal position. situations
activities that resemble the stress current affairs Nurse Nina should?
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d. The client maintains contact with a crisis ANSWERS and RATIONALES for PSYCHIATRIC 17. D. The nurse needs to set limits in the client’s
counselor NURSING Part 1 manipulative behavior to help the client control
49. Nurse Tina is caring for a client with depression dysfunctional behavior. A consistent approach by the
who has not responded to antidepressant 1. C. Total abstinence is the only effective treatment for staff is necessary to decrease manipulation.
medication. The nurse anticipates that what alcoholism. 18. B. Any suicidal statement must be assessed by the
treatment procedure may be prescribed? 2. A. Hallucinations are visual, auditory, gustatory, tactile nurse. The nurse should discuss the client’s
a. Neuroleptic medication or olfactory perceptions that have no basis in reality. statement with her to determine its meaning in
b. Short term seclusion 3. D. The Nurse has a responsibility to observe terms of suicide.
c. Psychosurgery continuously the acutely suicidal client. The Nurse 19. A. When the staff member ask the client if he
d. Electroconvulsive therapy should watch for clues, such as communicating wonders why others find him repulsive, the client is
50. Mario is admitted to the emergency room with suicidal thoughts, and messages; hoarding likely to feel defensive because the question is
drug-included anxiety related to over ingestion of medications and talking about death. belittling. The natural tendency is to counterattack
prescribed antipsychotic medication. The most 4. B. Establishing a consistent eating plan and monitoring the threat to self image.
important piece of information the nurse in charge client’s weight are important to this disorder. 20. B. The nurse would specifically use supportive
should obtain initially is the: 5. C. Appropriate nursing interventions for an anxiety confrontation with the client to point out
a. Length of time on the med. attack include using short sentences, staying with discrepancies between what the client states and
b. Name of the ingested medication & the the client, decreasing stimuli, remaining calm and what actually exists to increase responsibility for
amount ingested medicating as needed. self.
c. Reason for the suicide attempt 6. B. Delusion of grandeur is a false belief that one is 21. C. The nurse would most likely administer
d. Name of the nearest relative & their phone highly famous and important. benzodiazepine, such as lorazepan (ativan) to the
number 7. D. Individual with dependent personality disorder client who is experiencing symptom: The client’s
typically shows indecisiveness submissiveness and experiences symptoms of withdrawal because of the
clinging behavior so that others will make decisions rebound phenomenon when the sedation of the CNS
with them. from alcohol begins to decrease.
8. A. Clients with schizotypal personality disorder 22. D. Regular coffee contains caffeine which acts as
experience excessive social anxiety that can lead to psychomotor stimulants and leads to feelings of
paranoid thoughts. anxiety and agitation. Serving coffee top the client
9. B. Bulimia disorder generally is a maladaptive coping may add to tremors or wakefulness.
response to stress and underlying issues. The client 23. D. Vomiting and diarrhea are usually the late signs of
should identify anxiety causing situation that heroin withdrawal, along with muscle spasm, fever,
stimulate the bulimic behavior and then learn new nausea, repetitive, abdominal cramps and backache.
ways of coping with the anxiety. 24. D. Moving to a client’s personal space increases the
10. A. An adult age 31 to 45 generates new level of feeling of threat, which increases anxiety.
awareness. 25. A. Environmental (MILIEU) therapy aims at having
11. A. Neuromuscular Blocker, such as everything in the client’s surrounding area toward
SUCCINYLCHOLINE (Anectine) produces respiratory helping the client.
depression because it inhibits contractions of 26. C. Children who have experienced attachment
respiratory muscles. difficulties with primary caregiver are not able to
12. C. With depression, there is little or no emotional trust others and therefore relate superficially
involvement therefore little alteration in affect. 27. A. Children have difficulty verbally expressing their
13. D. These clients often hide food or force vomiting; feelings, acting out behavior, such as temper
therefore they must be carefully monitored. tantrums, may indicate underlying depression.
14. A. These clients have severely depleted levels of 28. D. The autistic child repeat sounds or words spoken
sodium and potassium because of their starvation by others.
diet and energy expenditure, these electrolytes are 29. D. The client statement is an example of the use of
necessary for cardiac functioning. denial, a defense that blocks problem by
15. B. Limiting unnecessary interaction will decrease unconscious refusing to admit they exist.
stimulation and agitation. 30. A. Discussion of the feared object triggers an
16. C. Ritualistic behavior seen in this disorder is aimed emotional response to the object.
at controlling guilt and inadequacy by maintaining an 31. B. The nurse presence may provide the client with
absolute set pattern of behavior. support & feeling of control.
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32. D. Experiencing the actual trauma in dreams or 49. D. Electroconvulsive therapy is an effective PSYCHIATRIC NURSING Part 2 c. Psychoanalysis
flashback is the major symptom that distinguishes treatment for depression that has not responded to d. Antidepressant therapy
post traumatic stress disorder from other anxiety medication. 1. Nurse Tony should first discuss terminating the nurse- 7. Danny who is diagnosed with bipolar disorder and
disorder. 50. B. In an emergency, lives saving facts are obtained client relationship with a client during the: acute mania, states the nurse, “Where is my
33. C. Confabulation or the filling in of memory gaps with first. The name and the amount of medication a. Termination phase when discharge plans are daughter? I love Louis. Rain, rain go away. Dogs eat
imaginary facts is a defense mechanism used by ingested are of outmost important in treating this being made. dirt.” The nurse interprets these statements as
people experiencing memory deficits. potentially life threatening situation. b. Working phase when the client shows some indicating which of the following?
34. A. These are the major signs of anorexia nervosa. progress. a. Echolalia
Weight loss is excessive (15% of expected weight). c. Orientation phase when a contract is b. Neologism
35. C. Dental enamel erosion occurs from repeated self- established. c. Clang associations
induced vomiting. d. Working phase when the client brings it up. d. Flight of ideas
36. B. Depression usually is both emotional & physical. A 2. Malou is diagnosed with major depression spends 8. Terry with mania is skipping up and down the hallway
simple daily routine is the best, least stressful and majority of the day lying in bed with the sheet pulled practically running into other clients. Which of the
least anxiety producing. over his head. Which of the following approaches by following activities would the nurse in charge expect
37. D. The expression of these feeling may indicate that the nurse would be the most therapeutic? to include in Terry’s plan of care?
this client is unable to continue the struggle of life. a. Question the client until he responds a. Watching TV
38. A. Structure tends to decrease agitation and anxiety b. Initiate contact with the client frequently b. Cleaning dayroom tables
and to increase the client’s feeling of security. c. Sit outside the clients room c. Leading group activity
39. B. The rituals used by a client with obsessive d. Wait for the client to begin the conversation d. Reading a book
compulsive disorder help control the anxiety level by 3. Joe who is very depressed exhibits psychomotor 9. When assessing a male client for suicidal risk, which of
maintaining a set pattern of action. retardation, a flat affect and apathy. The nurse in the following methods of suicide would the nurse
40. C. A person with this disorder would not have charge observes Joe to be in need of grooming and identify as most lethal?
adequate self-boundaries. hygiene. Which of the following nursing actions a. Wrist cutting
41. D. Loose associations are thoughts that are would be most appropriate? b. Head banging
presented without the logical connections usually a. Waiting until the client’s family can participate c. Use of gun
necessary for the listening to interpret the message. in the client’s care d. Aspirin overdose
42. C. Helping the client to develop feeling of self worth b. Asking the client if he is ready to take shower 10. Jun has been hospitalized for major depression and
would reduce the client’s need to use pathologic c. Explaining the importance of hygiene to the suicidal ideation. Which of the following statements
defenses. client indicates to the nurse that the client is improving?
43. B. Open ended questions and silence are strategies d. Stating to the client that it’s time for him to take a. “I’m of no use to anyone anymore.”
used to encourage clients to discuss their problem in a shower b. “I know my kids don’t need me anymore since
descriptive manner. 4. When teaching Mario with a typical depression about they’re grown.”
44. C. Clients who are withdrawn may be immobile and foods to avoid while taking phenelzine(Nardil), which c. “I couldn’t kill myself because I don’t want to go
mute, and require consistent, repeated of the following would the nurse in charge include? to hell.”
interventions. Communication with withdrawn a. Roasted chicken d. “I don’t think about killing myself as much as I
clients requires much patience from the nurse. The b. Fresh fish used to.”
nurse facilitates communication with the client by c. Salami 11. Which of the following activities would Nurse Trish
sitting in silence, asking open-ended question and d. Hamburger recommend to the client who becomes very anxious
pausing to provide opportunities for the client to 5. When assessing a female client who is receiving when thoughts of suicide occur?
respond. tricyclic antidepressant therapy, which of the following a. Using exercise bicycle
45. D. When hallucination is present, the nurse should would b. Meditating
reinforce reality with the client. alert the nurse to the possibility that the client is c. Watching TV
46. A. Personal characteristics of abuser include low self- experiencing anticholinergic effects? d. Reading comics
esteem, immaturity, dependence, insecurity and a. Urine retention and blurred vision 12. When developing the plan of care for a client
jealousy. b. Respiratory depression and convulsion receiving haloperidol, which of the following
47. D. A short acting skeletal muscle relaxant such as c. Delirium and Sedation medications would nurse Monet anticipate
succinylcholine (Anectine) is administered during d. Tremors and cardiac arrhythmias administering if the client developed extra pyramidal
this procedure to prevent injuries during seizure. 6. For a male client with dysthymic disorder, which of side effects?
48. C. Recognizing situations that produce anxiety allows the following approaches would the nurse expect to a. Olanzapine (Zyprexa)
the client to prepare to cope with anxiety or avoid implement? b. Paroxetine (Paxil)
specific stimulus. a. ECT c. Benztropine mesylate (Cogentin)
b. Psychotherapeutic approach d. Lorazepam (Ativan)
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13. Jon a suspicious client states that “I know you nurses socialize during activities without being seductive. of barbiturates is comatose. Nurse Trish would be d. Take the client a lunch tray and let the client eat
are spraying my food with poison as you take it out Nurse John would focus the discussion on which of especially alert for which of the following? in his room
of the cart.” Which of the following would be the the following areas? a. Epilepsy 30. The initial nursing intervention for the significant-
best response of the nurse? a. Discussing his relationship with his mother b. Myocardial Infarction others during shock phase of a grief reaction should
a. Giving the client canned supplements until the b. Asking him to explain reasons for his seductive c. Renal failure be focused on:
delusion subsides behavior d. Respiratory failure a. Presenting full reality of the loss of the
b. Asking what kind of poison the client suspects is c. Suggesting to apologize to others for his 25. Joey who has a chronic user of cocaine reports that individuals
being used behavior he feels like he has cockroaches crawling under his b. Directing the individual’s activities at this time
c. Serving foods that come in sealed packages d. Explaining the negative reactions of others skin. His arms are red because of scratching. The c. Staying with the individuals involved
d. Allowing the client to be the first to open the toward his behavior nurse in charge interprets these findings as possibly d. Mobilizing the individual’s support system
cart and get a tray 19. Tina with a histrionic personality disorder is indicating which of the following? 31. Joy’s stream of consciousness is occupied exclusively
14. A client is suffering from catatonic behaviors. Which melodramatic and responds to others and situations a. Delusion with thoughts of her father’s death. Nurse Ronald
of the following would the nurse use to determine in an exaggerated manner. Nurse Trish would b. Formication should plan to help Joy through this stage of
that the medication administered PRN have been recommend which of the following activities for c. Flash back grieving, which is known as:
most effective? Tina? d. Confusion a. Shock and disbelief
a. The client responds to verbal directions to eat a. Baking class 26. Jose is diagnosed with amphetamine psychosis and b. Developing awareness
b. The client initiates simple activities without b. Role playing was admitted in the emergency room. Nurse Ronald c. Resolving the loss
direction c. Scrap book making would most likely prepare to administer which of the d. Restitution
c. The client walks with the nurse to her room d. Music group following medication? 32. When taking a health history from a female client
d. The client is able to move all extremities 20. Joy has entered the chemical dependency unit for a. Librium who has a moderate level of cognitive impairment
occasionally treatment of alcohol dependency. Which of the b. Valium due to dementia, the nurse would expect to note the
15. Nurse Hazel invites new client’s parents to attend the following client’s possession will the nurse most c. Ativan presence of:
psycho educational program for families of the likely place in a locked area? d. Haldol a. Accentuated premorbid traits
chronically mentally ill. The program would be most a. Toothpaste 27. Which of the following liquids would nurse Leng b. Enhance intelligence
likely to help the family with which of the following b. Shampoo administer to a female client who is intoxicated with c. Increased inhibitions
issues? c. Antiseptic mouthwash phencyclidine (PCP) to hasten excretion of the d. Hyper vigilance
a. Developing a support network with other d. Moisturizer chemical? 33. What is the priority care for a client with a dementia
families 21. Which of the following assessment would provide a. Shake resulting from AIDS?
b. Feeling more guilty about the client’s illness the best information about the client’s physiologic b. Tea a. Planning for remotivational therapy
c. Recognizing the client’s weakness response and the effectiveness of the medication c. Cranberry Juice b. Arranging for long term custodial care
d. Managing their financial concern and problems prescribed specifically for alcohol withdrawal? d. Grape juice c. Providing basic intellectual stimulation
16. When planning care for Dory with schizotypal a. Sleeping pattern 28. When developing a plan of care for a female client d. Assessing pain frequently
personality disorder, which of the following would b. Mental alertness with acute stress disorder who lost her sister in a car 34. Jerome who has eating disorder often exhibits similar
help the client become involved with others? c. Nutritional status accident. Which of the following would the nurse symptoms. Nurse Lhey would expect an adolescent
a. Attending an activity with the nurse d. Vital signs expect to initiate? client with anorexia to exhibit:
b. Leading a sing a long in the afternoon 22. After administering naloxone (Narcan), an opioid a. Facilitating progressive review of the accident a. Affective instability
c. Participating solely in group activities antagonist, Nurse Ronald should monitor the female and its consequences b. Dishered, unkempt physical appearance
d. Being involved with primarily one to one client carefully for which of the following? b. Postponing discussion of the accident until the c. Depersonalization and derealization
activities a. Respiratory depression client brings it up d. Repetitive motor mechanisms
17. Which statement about an individual with a b. Epilepsy c. Telling the client to avoid details of the accident 35. The primary nursing diagnosis for a female client
personality disorder is true? c. Kidney failure d. Helping the client to evaluate her sister’s with a medical diagnosis of major depression would
a. Psychotic behavior is common during acute d. Cerebral edema behavior be:
episodes 23. Which of the following would nurse Ronald use as 29. The nursing assistant tells nurse Ronald that the a. Situational low self-esteem related to altered
b. Prognosis for recovery is good with therapeutic the best measure to determine a client’s progress in client is not in the dining room for lunch. Nurse role
intervention rehabilitation? Ronald would direct the nursing assistant to do b. Powerlessness related to the loss of idealized
c. The individual typically remains in the a. The way he gets along with his parents which of the following? self
mainstream of society, although he has problems in b. The number of drug-free days he has a. Tell the client he’ll need to wait until supper to c. Spiritual distress related to depression
social and occupational roles c. The kinds of friends he makes eat if he misses lunch d. Impaired verbal communication related to
d. The individual usually seeks treatment willingly d. The amount of responsibility his job entails b. Invite the client to lunch and accompany him to depression
for symptoms that are personally distressful. 24. A female client is brought by ambulance to the the dining room 36. When developing an initial nursing care plan for a
18. Nurse John is talking with a client who has been hospital emergency room after taking an overdose c. Inform the client that he has 10 minutes to get male client with a Bipolar I disorder (manic episode)
diagnosed with antisocial personality about how to to the dining room for lunch nurse Ron should plan to?
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a. Isolate his gym time have turned to glass!” Nurse Ron is aware that this is b. Providing the client with activities in which
b. Encourage his active participation in unit an example of: success can be achieved
programs a. Somatic delusions c. Removing stress so that the client can relax
c. Provide foods, fluids and rest b. Depersonalization d. Not placing any demands on the client
d. Encourage his participation in programs c. Hypochondriasis 49. Nurse Gerry is aware that the defense mechanism
37. Grace is exhibiting withdrawn patterns of behavior. d. Echolalia commonly used by clients who are alcoholics is:
Nurse Johnny is aware that this type of behavior 43. In recognizing common behaviors exhibited by male a. Displacement
eventually produces feeling of: client who has a diagnosis of schizophrenia, nurse b. Denial
a. Repression Josie can anticipate: c. Projection
b. Loneliness a. Slumped posture, pessimistic out look and flight d. Compensation
c. Anger of ideas 50. Within a few hours of alcohol withdrawal, nurse John
d. Paranoia b. Grandiosity, arrogance and distractibility should assess the male client for the presence of:
38. One morning a female client on the inpatient c. Withdrawal, regressed behavior and lack of a. Disorientation, paranoia, tachycardia
psychiatric service complains to nurse Hazel that she social skills b. Tremors, fever, profuse diaphoresis
has been waiting for over an hour for someone to d. Disorientation, forgetfulness and anxiety c. Irritability, heightened alertness, jerky
accompany her to activities. Nurse Hazel replies to 44. One morning, nurse Diane finds a disturbed client movements
the client “We’re doing the best we can. There are a curled up in the fetal position in the corner of the d. Yawning, anxiety, convulsions
lot of other people on the unit who needs attention dayroom. The most accurate initial evaluation of the
too.” This statement shows that the nurse’s use of: behavior would be that the client is:
a. Defensive behavior a. Physically ill and experiencing abdominal
b. Reality reinforcement discomfort
c. Limit-setting behavior b. Tired and probably did not sleep well last night
d. Impulse control c. Attempting to hide from the nurse
39. A nursing diagnosis for a male client with a d. Feeling more anxious today
diagnosed multiple personality disorder is chronic 45. Nurse Bea notices a female client sitting alone in the
low self-esteem probably related to childhood corner smiling and talking to herself. Realizing that
abuse. The most appropriate short term client the client is hallucinating. Nurse Bea should:
outcome would be: a. Invite the client to help decorate the dayroom
a. Verbalizing the need for anxiety medications b. Leave the client alone until he stops talking
b. Recognizing each existing personality c. Ask the client why he is smiling and talking
c. Engaging in object-oriented activities d. Tell the client it is not good for him to talk to
d. Eliminating defense mechanisms and phobia himself
40. A 25 year old male is admitted to a mental health 46. When being admitted to a mental health facility, a
facility because of inappropriate behavior. The client young female adult tells Nurse Mylene that the
has been hearing voices, responding to imaginary voices she hears frighten her. Nurse Mylene
companions and withdrawing to his room for several understands that the client tends to hallucinate
days at a time. Nurse Monette understands that the more vividly:
withdrawal is a defense against the client’s fear of: a. While watching TV
a. Phobia b. During meal time
b. Powerlessness c. During group activities
c. Punishment d. After going to bed
d. Rejection 47. Nurse John recognizes that paranoid delusions
41. When asking the parents about the onset of usually are related to the defense mechanism of:
problems in young client with the diagnosis of a. Projection
schizophrenia, Nurse Linda would expect that they b. Identification
would relate the client’s difficulties began in: c. Repression
a. Early childhood d. Regression
b. Late childhood 48. When planning care for a male client using paranoid
c. Adolescence ideation, nurse Jasmin should realize the importance
d. Puberty of:
42. Jose who has been hospitalized with schizophrenia a. Giving the client difficult tasks to provide
tells Nurse Ron, “My heart has stopped and my veins stimulation
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ANSWERS and RATIONALES for PSYCHIATRIC (Haldol) is benztropine mesylate (cogentin) clearly indicates that the product does not dependence on environment & social structure
NURSING Part 2 because of its anti cholinergic properties. contain alcohol. and by increasing psychologic rigidity with
13. D. Allowing the client to be the first to open the 21. D. Monitoring of vital signs provides the best accentuated previous traits & behaviors.
1. C. When the nurse and client agree to work cart & take a tray presents the client with the information about the client’s overall physiologic 33. C. This action maintains for as long as possible,
together, a contract should be established, the reality that the nurses are not touching the food status during alcohol withdrawal & the the clients intellectual functions by providing an
length of the relationship should be discussed in & tray, thereby dispelling the delusion. physiologic response to the medication used. opportunity to use them.
terms of its ultimate termination. 14. B. Although all the actions indicate 22. A. After administering naloxone (Narcan) the 34. A. Individuals with anorexia often display
2. B. The nurse should initiate brief, frequent improvement, the ability to initiate simple nurse should monitor the client’s respiratory irritability, hospitality, and a depressed mood.
contacts throughout the day to let the client activities without directions indicates the most status carefully, because the drug is short acting 35. D. Depressed clients demonstrate decreased
know that he is important to the nurse. This will improvement in the catatonic behaviors. & respiratory depression may recur after its communication because of lack of psychic or
positively affect the client’s self-esteem. 15. A. Psychoeducational groups for families effects wear off. physical energy.
3. D. The client with depression is preoccupied, has develop a support network. They provide 23. B. The best measure to determine a client’s 36. C. The client in a manic episode of the illness
decreased energy, and is unable to make education about the biochemical etiology of progress in rehabilitation is the number of drug- often neglects basic needs, these needs are a
decisions. The nurse presents the situation, “It’s psychiatric disease to reduce, not increase family free days he has. The longer the client is free of priority to ensure adequate nutrition, fluid, and
time for a shower”, and assists the client with guilt. drugs, the better the prognosis is. rest.
personal hygiene to preserve his dignity and self- 16. C. Attending activity with the nurse assists the 24. D. Barbiturates are CNS depressants; the nurse 37. B. The withdrawn pattern of behavior presents
esteem. client to become involved with others slowly. would be especially alert for the possibility of the individual from reaching out to others for
4. C. Foods high in tyramine, those that are The client with schizotypal personality disorder respiratory failure. Respiratory failure is the sharing the isolation produces feeling of
fermented, pickled, aged, or smoked must be needs support, kindness & gentle suggestion to most likely cause of death from barbiturate over loneliness.
avoided because when they are ingested in improve social skills & interpersonal relationship. dose. 38. A. The nurse’s response is not therapeutic
combination with MAOIs a hypertensive crisis 17. C. An individual with personality disorder usually 25. B. The feeling of bugs crawling under the skin is because it does not recognize the client’s needs
will occur. is not hospitalized unless a coexisting Axis I termed as formication, and is associated with but tries to make the client feel guilty for being
5. A. Anticholinergic effects, which result from psychiatric disorder is present. Generally, these cocaine use. demanding.
blockage of the parasympathetic (craniosacral) individuals make marginal adjustments and 26. D. The nurse would prepare to administer an 39. B. The client must recognize the existence of the
nervous system including urine retention, remain in society, although they typically antipsychotic medication such as Haldol to a sub personalities so that interpretation can
blurred vision, dry mouth & constipation. experience relationship and occupational client experiencing amphetamine psychosis to occur.
6. B. Dysthymia is a less severe, chronic depression problems related to their inflexible behaviors. decrease agitation & psychotic symptoms, 40. D. An aloof, detached, withdrawn posture is a
diagnosed when a client has had a depressed Personality disorders are chronic lifelong including delusions, hallucinations & cognitive means of protecting the self by withdrawing and
mood for more days than not over a period of at patterns of behavior; acute episodes do not impairment. maintaining a safe, emotional distance.
least 2 years. Client with dysthymic disorder occur. Psychotic behavior is usually not common, 27. C. An acid environment aids in the excretion of 41. C. The usual age of onset of schizophrenia is
benefit from psychotherapeutic approaches that although it can occur in either schizotypal PCP. The nurse will definitely give the client with adolescence or early childhood.
assist the client in reversing the negative self personality disorder or borderline personality PCP intoxication cranberry juice to acidify the 42. A. Somatic delusion is a fixed false belief about
image, negative feelings about the future. disorder. Because these disorders are enduring urine to a ph of 5.5 & accelerate excretion. one’s body.
7. D. Flight of ideas is speech pattern of rapid and evasive and the individual is inflexible, 28. A. The nurse would facilitate progressive review 43. C. These are the classic behaviors exhibited by
transition from topic to topic, often without prognosis for recovery is unfavorable. Generally, of the accident and its consequence to help the clients with a diagnosis of schizophrenia.
finishing one idea. It is common in mania. the individual does not seek treatment because client integrate feelings & memories and to 44. D. The fetal position represents regressed
8. B. The client with mania is very active & needs to he does not perceive problems with his own begin the grieving process. behavior. Regression is a way of responding to
have this energy channeled in a constructive task behavior. Distress can occur based on other 29. B. The nurse instructs the nursing assistant to overwhelming anxiety.
such as cleaning or tidying the room. people’s reaction to the individual’s behavior. invite the client to lunch & accompany him to 45. B. This provides a stimulus that competes with
9. C. A crucial factor is determining the lethality of 18. D. The nurse would explain the negative the dinning room to decrease manipulation, and reduces hallucination.
a method is the amount of time that occurs reactions of others towards the client’s secondary gain, dependency and reinforcement 46. D. Auditory hallucinations are most troublesome
between initiating the method & the delivery of behaviors to make the clients aware of the of negative behavior while maintaining the when environmental stimuli are diminished and
the lethal impact of the method. impact of his seductive behaviors on others. client’s worth. there are few competing distractions.
10. D. The statement “I don’t think about killing 19. B. The nurse would use role-playing to teach the 30. C. This provides support until the individuals 47. A. Projection is a mechanism in which inner
myself as much as I used to.” Indicates a client appropriate responses to others and in coping mechanisms and personal support thoughts and feelings are projected onto the
lessening of suicidal ideation and improvement various situations. This client dramatizes events, systems can be immobilized. environment, seeming to come from outside the
in the client’s condition. drawn attention to self, and is unaware of and 31. C. Resolving a loss is a slow, painful, continuous self rather than from within.
11. A. Using exercise bicycle is appropriate for the does not deal with feelings. The nurse works to process until a mental image of the dead person, 48. B. This will help the client develop self-esteem
client who becomes very anxious when thoughts help the client clarify true feelings & learn to almost devoid of negative or undesirable and reduce the use of paranoid ideation.
of suicidal occur. express them appropriately. features emerges. 49. B. Denial is a method of resolving conflict or
12. C. The drug of choice for a client experiencing 20. C. Antiseptic mouthwash often contains alcohol 32. A. A moderate level of cognitive impairment due escaping unpleasant realities by ignoring their
extra pyramidal side effects from haloperidol & should be kept in locked area, unless labeling to dementia is characterized by increasing existence.
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50. C. Alcohol is a central nervous system PSYCHIATRIC NURSING Part 3 a. Projection

depressant. These symptoms are the body’s b. Displacement
neurologic adaptation to the withdrawal of 1. Francis who is addicted to cocaine withdraws from the c. Denial
alcohol. drug. Nurse Ron should expect to observe: d. Reaction formation
a. Hyperactivity 8. The most critical factor for nurse Linda to determine
b. Depression during crisis intervention would be the client’s:
c. Suspicion a. Available situational supports
d. Delirium b. Willingness to restructure the personality
2. Nurse John is aware that a serious effect of inhaling c. Developmental theory
cocaine is? d. Underlying unconscious conflict
a. Deterioration of nasal septum 9. Nurse Trish suggests a crisis intervention group to a
b. Acute fluid and electrolyte imbalances client experiencing a developmental crisis. These
c. Extra pyramidal tract symptoms groups are successful because the:
d. Esophageal varices a. Crisis intervention worker is a psychologist
3. A tentative diagnosis of opiate addiction, Nurse Candy and understands behavior patterns
should assess a recently hospitalized client for signs b. Crisis group supplies a workable solution to
of opiate withdrawal. These signs would include: the client’s problem
a. Rhinorrhea, convulsions, subnormal c. Client is encouraged to talk about personal
temperature problems
b. Nausea, dilated pupils, constipation d. Client is assisted to investigate alternative
c. Lacrimation, vomiting, drowsiness approaches to solving the identified problem
d. Muscle aches, papillary constriction, yawning 10. Nurse Ronald could evaluate that the staff’s
4. A 48 year old male client is brought to the psychiatric approach to setting limits for a demanding, angry
emergency room after attempting to jump off a client was effective if the client:
bridge. The client’s wife states that he lost his job a. Apologizes for disrupting the unit’s routine
several months ago and has been unable to find when something is needed
another job. The primary nursing intervention at this b. Understands the reason why frequent calls to
time would be to assess for: the staff were made
a. A past history of depression c. Discuss concerns regarding the emotional
b. Current plans to commit suicide condition that required hospitalizations
c. The presence of marital difficulties d. No longer calls the nursing staff for assistance
d. Feelings of excessive failure 11. Nurse John is aware that the therapy that has the
5. Before helping a male client who has been sexually highest success rate for people with phobias would
assaulted, nurse Maureen should recognize that the be:
rapist is motivated by feelings of: a. Psychotherapy aimed at rearranging maladaptive
a. Hostility thought process
b. Inadequacy b. Psychoanalytical exploration of repressed conflicts
c. Incompetence of an earlier development phase
d. Passion c. Systematic desensitization using relaxation
6. When working with children who have been sexually technique
abused by a family member it is important for the d. Insight therapy to determine the origin of the
nurse to understand that these victims usually are anxiety and fear
overwhelmed with feelings of: 12. When nurse Hazel considers a client’s placement on
a. Humiliation the continuum of anxiety, a key in determining the
b. Confusion degree of anxiety being experienced is the client’s:
c. Self blame a. Perceptual field
d. Hatred b. Delusional system
7. Joy who has just experienced her second spontaneous c. Memory state
abortion expresses anger towards her physician, the d. Creativity level
hospital and the “rotten nursing care”. When 13. In the diagnosis of a possible pervasive
assessing the situation, the nurse recognizes that the developmental autistic disorder. The nurse would
client may be using the coping mechanism of:
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find it most unusual for a 3 year old child to d. Decreased respiratory rate 26. Rosana is in the second stage of Alzheimer’s disease b. Don’t consume alcohol
demonstrate: 20. Initial interventions for Marco with acute anxiety who appears to be in pain. Which question by Nurse c. Discontinue if dry mouth and blurred vision occur
a. An interest in music include all except which of the following? Jenny would best elicit information about the pain? d. Restrict fluid and sodium intake
b. An attachment to odd objects a. Touching the client in an attempt to comfort him a. “Where is your pain located?” 33. Important teaching for women in their childbearing
c. Ritualistic behavior b. Approaching the client in calm, confident manner b. “Do you hurt? (pause) “Do you hurt?” years who are receiving antipsychotic medications
d. Responsiveness to the parents c. Encouraging the client to verbalize feelings and c. “Can you describe your pain?” includes which of the following?
14. Malou with schizophrenia tells Nurse Melinda, “My concerns d. “Where do you hurt?” a. Increased incidence of dysmenorrhea while taking
intestines are rotted from worms chewing on them.” d. Providing the client with a safe, quiet and private 27. Nursing preparation for a client undergoing the drug
This statement indicates a: place electroconvulsive therapy (ECT) resemble those used b. Occurrence of incomplete libido due to
a. Jealous delusion 21. Nurse Jessie is assessing a client suffering from stress for: medication adverse effects
b. Somatic delusion and anxiety. A common physiological response to a. General anesthesia c. Continuing previous use of contraception during
c. Delusion of grandeur stress and anxiety is: b. Cardiac stress testing periods of amenorrhea
d. Delusion of persecution a. Uticaria c. Neurologic examination d. Instruction that amenorrhea is irreversible
15. Andy is admitted to the psychiatric unit with a b. Vertigo d. Physical therapy 34. A client refuses to remain on psychotropic
diagnosis of borderline personality disorder. Nurse c. Sedation 28. Jose who is receiving monoamine oxidase inhibitor medications after discharge from an inpatient
Hilary should expects the assessment to reveal: d. Diarrhea antidepressant should avoid tyramine, a compound psychiatric unit. Which information should the
a. Coldness, detachment and lack of tender feelings 22. When performing a physical examination on a female found in which of the following foods? community health nurse assess first during the initial
b. Somatic symptoms anxious client, nurse Nelli would expect to find a. Figs and cream cheese follow-up with this client?
c. Inability to function as responsible parent which of the following effects produced by the b. Fruits and yellow vegetables a. Income level and living arrangements
d. Unpredictable behavior and intense interpersonal parasympathetic system? c. Aged cheese and Chianti wine b. Involvement of family and support systems
relationships a. Muscle tension d. Green leafy vegetables c. Reason for inpatient admission
16. PROPRANOLOL (Inderal) is used in the mental health b. Hyperactive bowel sounds 29. Erlinda, age 85, with major depression d. Reason for refusal to take medications
setting to manage which of the following conditions? c. Decreased urine output undergoes a sixth electroconvulsive therapy (ECT) 35. The nurse understands that the therapeutic effects
a. Antipsychotic – induced akathisia and anxiety d. Constipation treatment. When assessing the client immediately of typical antipsychotic medications are associated
b. Obsessive – compulsive disorder (OCD) to reduce 23. Which of the following drugs have been known to be after ECT, the nurse expects to find: with which neurotransmitter change?
ritualistic behavior effective in treating obsessive-compulsive disorder a. Permanent short-term memory loss and a. Decreased dopamine level
c. Delusions for clients suffering from schizophrenia (OCD)? hypertension b. Increased acetylcholine level
d. The manic phase of bipolar illness as a mood a. Divalproex (depakote) and Lithium (lithobid) b. Permanent long-term memory loss and c. Stabilization of serotonin
stabilizer b. Chlordiazepoxide (Librium) and diazepam (valium) hypomania d. Stimulation of GABA
17. Which medication can control the extra pyramidal c. Fluvoxamine (Luvox) and clomipramine (anafranil) c. Transitory short-term memory loss and permanent 36. Which of the following best explains why tricyclic
effects associated with antipsychotic agents? d. Benztropine (Cogentin) and diphenhydramine long-term memory loss antidepressants are used with caution in elderly
a. Clorazepate (Tranxene) (benadryl) d. Transitory short and long term memory loss and patients?
b. Amantadine (Symmetrel) 24. Tony with agoraphobia has been symptom-free for 4 confusion a. Central Nervous System effects
c. Doxepin (Sinequan) months. Classic signs and symptoms of phobia 30. Barbara with bipolar disorder is being treated with b. Cardiovascular system effects
d. Perphenazine (Trilafon) include: lithium for the first time. Nurse Clint should observe c. Gastrointestinal system effects
18. Which of the following statements should be a. Severe anxiety and fear the client for which common adverse effect of d. Serotonin syndrome effects
included when teaching clients about monoamine b. Withdrawal and failure to distinguish reality from lithium? 37. A client with depressive symptoms is given
oxidase inhibitor (MAOI) antidepressants? fantasy a. Polyuria prescribed medications and talks with his therapist
a. Don’t take aspirin or nonsteroidal anti- c. Depression and weight loss b. Seizures about his belief that he is worthless and unable to
inflammatory drugs (NSAIDs) d. Insomnia and inability to concentrate c. Constipation cope with life. Psychiatric care in this treatment plan
b. Have blood levels screened weekly for leucopenia 25. Which nursing action is most appropriate when d. Sexual dysfunction is based on which framework?
c. Avoid strenuous activity because of the cardiac trying to diffuse a client’s impending violent 31. Nurse Fred is assessing a client who has just been a. Behavioral framework
effects of the drug behavior? admitted to the ER department. Which signs would b. Cognitive framework
d. Don’t take prescribed or over the counter a. Place the client in seclusion suggest an overdose of an antianxiety agent? c. Interpersonal framework
medications without consulting the physician b. Leaving the client alone until he can talk about his a. Suspiciousness, dilated pupils and incomplete BP d. Psychodynamic framework
19. Kris periodically has acute panic attacks. These feelings b. Agitation, hyperactivity and grandiose ideation 38. A nurse who explains that a client’s psychotic
attacks are unpredictable and have no apparent c. Involving the client in a quiet activity to divert c. Combativeness, sweating and confusion behavior is unconsciously motivated understands
association with a specific object or situation. During attention d. Emotional lability, euphoria and impaired memory that the client’s disordered behavior arises from
an acute panic attack, Kris may experience: d. Helping the client identify and express feelings of 32. Discharge instructions for a male client receiving which of the following?
a. Heightened concentration anxiety and anger tricyclic antidepressants include which of the a. Abnormal thinking
b. Decreased perceptual field following information? b. Altered neurotransmitters
c. Decreased cardiac rate a. Restrict fluids and sodium intake c. Internal needs
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d. Response to stimuli 45. Which nursing diagnosis is most appropriate for a ANSWERS and RATIONALES for PSYCHIATRIC 16. A. Propranolol is a potent beta adrenergic blocker
39. A client with depression has been hospitalized for client with anorexia nervosa who expresses feelings NURSING Part 3 and producing a sedating effect, therefore it is used
treatment after taking a leave of absence from work. of guilt about not meeting family expectations? to treat antipsychotic induced akathisia and anxiety.
The client’s employer expects the client to return to a. Anxiety 1. B. There is no set of symptoms associated with 17. B. Amantadine is an anticholinergic drug used to
work following inpatient treatment. The client tells b. Disturbed body image cocaine withdrawal, only the depression that follows relive drug-induced extra pyramidal adverse effects
the nurse, “I’m no good. I’m a failure”. According to c. Defensive coping the high caused by the drug. such as muscle weakness, involuntary muscle
cognitive theory, these statements reflect: d. Powerlessness 2. A. Cocaine is a chemical that when inhaled, causes movements, pseudoparkinsonism and tar dive
a. Learned behavior 46. A nurse is evaluating therapy with the family of a destruction of the mucous membranes of the nose. dyskinesia.
b. Punitive superego and decreased self-esteem client with anorexia nervosa. Which of the following 3. D. These adaptations are associated with opiate 18. C. MAOI antidepressants when combined with a
c. Faulty thought processes that govern behavior would indicate that the therapy was successful? withdrawal which occurs after cessation or reduction number of drugs can cause life-threatening
d. Evidence of difficult relationships in the work a. The parents reinforced increased decision making of prolonged moderate or heavy use of opiates. hypertensive crisis. It’s imperative that a client
environment by the client 4. B. Whether there is a suicide plan is a criterion when checks with his physician and pharmacist before
40. The nurse describes a client as anxious. Which of the b. The parents clearly verbalize their expectations assessing the client’s determination to make another taking any other medications.
following statement about anxiety is true? for the client attempt. 19. B. Panic is the most severe level of anxiety. During
a. Anxiety is usually pathological c. The client verbalizes that family meals are now 5. A. Rapists are believed to harbor and act out hostile panic attack, the client experiences a decrease in the
b. Anxiety is directly observable enjoyable feelings toward all women through the act of rape. perceptual field, becoming more focused on self,
c. Anxiety is usually harmful d. The client tells her parents about feelings of low- 6. C. These children often have nonsexual needs met less aware of surroundings and unable to process
d. Anxiety is a response to a threat self esteem by individual and are powerless to refuse. information from the environment. The decreased
41. A client with a phobic disorder is treated by 47. A client with dysthymic disorder reports to a nurse Ambivalence results in self-blame and also guilt. perceptual field contributes to impaired attention
systematic desensitization. The nurse understands that his life is hopeless and will never improve in the 7. B. The client’s anger over the abortion is shifted to and inability to concentrate.
that this approach will do which of the following? future. How can the nurse best respond using a the staff and the hospital because she is unable to 20. A. The emergency nurse must establish rapport and
a. Help the client execute actions that are feared cognitive approach? deal with the abortion at this time. trust with the anxious client before using therapeutic
b. Help the client develop insight into irrational fears a. Agree with the client’s painful feelings 8. A. Personal internal strength and supportive touch. Touching an anxious client may actually
c. Help the client substitutes one fear for another b. Challenge the accuracy of the client’s belief individuals are critical factors that can be employed increase anxiety.
d. Help the client decrease anxiety c. Deny that the situation is hopeless to assist the individual to cope with a crisis. 21. D. Diarrhea is a common physiological response to
42. Which client outcome would best indicate successful d. Present a cheerful attitude 9. D. Crisis intervention group helps client reestablish stress and anxiety.
treatment for a client with an antisocial personality 48. A client with major depression has not verbalized psychologic equilibrium by assisting them to explore 22. B. The parasympathetic nervous system would
disorder? problem areas to staff or peers since admission to a new alternatives for coping. It considers realistic produce incomplete G.I. motility resulting in
a. The client exhibits charming behavior when psychiatric unit. Which activity should the nurse situations using rational and flexible problem solving hyperactive bowel sounds, possibly leading to
around authority figures recommend to help this client express himself? methods. diarrhea.
b. The client has decreased episodes of impulsive a. Art therapy in a small group 10. C. This would document that the client feels 23. C. The antidepressants fluvoxamine and
behaviors b. Basketball game with peers on the unit comfortable enough to discuss the problems that clomipramine have been effective in the treatment
c. The client makes statements of self-satisfaction c. Reading a self-help book on depression have motivated the behavior. of OCD.
d. The client’s statements indicate no remorse for d. Watching movie with the peer group 11. C. The most successful therapy for people with 24. A. Phobias cause severe anxiety (such as panic
behaviors 49. The home health psychiatric nurse visits a client with phobias involves behavior modification techniques attack) that is out of proportion to the threat of the
43. The nurse is caring for a client with an autoimmune chronic schizophrenia who was recently discharged using desensitization. feared object or situation. Physical signs and
disorder at a medical clinic, where alternative after a prolong stay in a state hospital. The client 12. A. Perceptual field is a key indicator of anxiety level symptoms of phobias include profuse sweating, poor
medicine is used as an adjunct to traditional lives in a boarding home, reports no family because the perceptual fields narrow as anxiety motor control, tachycardia and elevated B.P.
therapies. Which information should the nurse teach involvement, and has little social interaction. The increases. 25. D. In many instances, the nurse can diffuse
the client to help foster a sense of control over his nurse plan to refer the client to a day treatment 13. D. One of the symptoms of autistic child displays a impending violence by helping the client identify and
symptoms? program in order to help him with: lack of responsiveness to others. There is little or no express feelings of anger and anxiety. Such
a. Pathophysiology of disease process a. Managing his hallucinations extension to the external environment. statement as “What happened to get you this
b. Principles of good nutrition b. Medication teaching 14. B. Somatic delusions focus on bodily functions or angry?” may help the client verbalizes feelings rather
c. Side effects of medications c. Social skills training systems and commonly include delusion about foul than act on them.
d. Stress management techniques d. Vocational training odor emissions, insect manifestations, internal 26. B. When speaking to a client with Alzheimer’s
44. Which of the following is the most distinguishing 50. Which activity would be most appropriate for a parasites and misshapen parts. disease, the nurse should use close-ended questions.
feature of a client with an antisocial personality severely withdrawn client? 15. D. A client with borderline personality displays a Those that the client can answer with “yes” or “no”
disorder? a. Art activity with a staff member pervasive pattern of unpredictable behavior, mood whenever possible and avoid questions that require
a. Attention to detail and order b. Board game with a small group of clients and self image. Interpersonal relationships may be the client to make choices. Repeating the question
b. Bizarre mannerisms and thoughts c. Team sport in the gym intense and unstable and behavior may be aids comprehension.
c. Submissive and dependent behavior d. Watching TV in the dayroom inappropriate and impulsive. 27. A. The nurse should prepare a client for ECT in a
d. Disregard for social and legal norms manner similar to that for general anesthesia.
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28. C. Aged cheese and Chianti wine contain high Using medications to alter neurotransmitter activity will help reduce the physiologic stress response. This 49. C. Day treatment programs provide clients with
concentrations of tyramine. is a psychobiologic approach to treatment. The other will afford the client an increased sense of control chronic, persistent mental illness training in social
29. D. ECT commonly causes transitory short and long answer choices are frameworks for care, but hey are over his symptoms. The nurse can address the skills, such as meeting and greeting people, asking
term memory loss and confusion, especially in not applicable to this situation. remaining answer choices in her teaching about the questions or directions, placing an order in a
geriatric clients. It rarely results in permanent short 38. C. The concept that behavior is motivated and has client’s disease and treatment; however, knowledge restaurant, taking turns in a group setting activity.
and long term memory loss. meaning comes from the psychodynamic alone will not help the client to manage his stress Although management of hallucinations and
30. A. Polyuria commonly occurs early in the treatment framework. According to this perspective, behavior effectively enough to control symptoms. medication teaching may also be part of the
with lithium and could result in fluid volume deficit. arises from internal wishes or needs. Much of what 44. D. Disregard for established rules of society is the program offered in a day treatment, the nurse is
31. D. Signs of anxiety agent overdose include emotional motivates behavior comes from the unconscious. most common characteristic of a client with referring the client in this situation because of his
lability, euphoria and impaired memory. The remaining responses do not address the internal antisocial personality disorder. Attention to detail need for socialization skills. Vocational training
32. B. Drinking alcohol can potentiate the sedating forces thought to motivate behavior. and order is characteristic of someone with generally takes place in a rehabilitation facility; the
action of tricyclic antidepressants. Dry mouth and 39. C. The client is demonstrating faulty thought obsessive compulsive disorder. Bizarre mannerisms client described in this situation would not be a
blurred vision are normal adverse effects of tricyclic processes that are negative and that govern his and thoughts are characteristics of a client with candidate for this service.
antidepressants. behavior in his work situation – issues that are schizoid or schizotypal disorder. Submissive and 50. A. The best approach with a withdrawn client is to
33. C. Women may experience amenorrhea, which is typically examined using a cognitive theory dependent behaviors are characteristic of someone initiate brief, nondemanding activities on a one-to-
reversible, while taking antipsychotics. Amenorrhea approach. Issues involving learned behavior are best with a dependent personality. one basis. This approach gives the nurse an
doesn’t indicate cessation of ovulation thus, the explored through behavior theory, not cognitive 45. D. The client with anorexia typically feels powerless, opportunity to establish a trusting relationship with
client can still be pregnant. theory. Issues involving ego development are the with a sense of having little control over any aspect the client. A board game with a group clients or
34. D. The first are for assessment would be the client’s focus of psychoanalytic theory. Option 4 is incorrect of life besides eating behavior. Often, parental playing a team sport in the gym may overwhelm a
reason for refusing medication. The client may not because there is no evidence in this situation that expectations and standards are quite high and lead severely withdrawn client. Watching TV is a solitary
understand the purpose for the medication, may be the client has conflictual relationships in the work to the clients’ sense of guilt over not measuring up. activity that will reinforce the client’s withdrawal
experiencing distressing side effects, or may be environment. 46. A. One of the core issues concerning the family of a from others.
concerned about the cost of medicine. In any case, 40. D. Anxiety is a response to a threat arising from client with anorexia is control. The family’s
the nurse cannot provide appropriate intervention internal or external stimuli. acceptance of the client’s ability to make
before assessing the client’s problem with the 41. A. Systematic desensitization is a behavioral therapy independent decisions is key to successful family
medication. The patient’s income level, living technique that helps clients with irrational fears and intervention. Although the remaining options may
arrangements, and involvement of family and avoidance behavior to face the thing they fear, occur during the process of therapy, they would not
support systems are relevant issues following without experiencing anxiety. There is no attempt to necessarily indicate a successful outcome; the
determination of the client’s reason for refusing promote insight with this procedure, and the client central family issues of dependence and
medication. The nurse providing follow-up care will not be taught to substitute one fear for another. independence are not addresses on these responses.
would have access to the client’s medical record and Although the client’s anxiety may decrease with 47. B. Use of cognitive techniques allows the nurse to
should already know the reason for inpatient successful confrontation of irrational fears, the help the client recognize that this negative beliefs
admission. purpose of the procedure is specifically related to may be distortions and that, by changing his
35. A. Excess dopamine is thought to be the chemical performing activities that typically are avoided as thinking, he can adopt more positive beliefs that are
cause for psychotic thinking. The typical part of the phobic response. realistic and hopeful. Agreeing with the client’s
antipsychotics act to block dopamine receptors and 42. B. A client with antisocial personality disorder feelings and presenting a cheerful attitude are not
therefore decrease the amount of neurotransmitter typically has frequent episodes of acting impulsively consistent with a cognitive approach and would not
at the synapses. The typical antipsychotics do not with poor ability to delay self-gratification. be helpful in this situation. Denying the client’s
increase acetylcholine, stabilize serotonin, stimulate Therefore, decreased frequency of impulsive feelings is belittling and may convey that the nurse
GABA. behaviors would be evidence of improvement. does not understand the depth of the client’s
36. B. The TCAs affect norepinephrine as well as other Charming behavior when around authority figures distress.
neurotransmitters, and thus have significant and statements indicating no remorse are examples 48. A. Art therapy provides a nonthreatening vehicle for
cardiovascular side effects. Therefore, they are used of symptoms typical of someone with this disorder the expression of feelings, and use of a small group
with caution in elderly clients who may have and would not indicate successful treatment. Self- will help the client become comfortable with peers
increased risk factors for cardiac problems because satisfaction would be viewed as a positive change if in a group setting. Basketball is a competitive game
of their age and other medical conditions. The the client expresses low self-esteem; however this is that requires energy; the client with major
remaining side effects would apply to any client not a characteristic of a client with antisocial depression is not likely to participate in this activity.
taking a TCA and are not particular to an elderly personality disorder. Recommending that the client read a self-help book
person. 43. D. In autoimmune disorders, stress and the response may increase, not decrease his isolation. Watching
37. B. Cognitive thinking therapy focuses on the client’s to stress can exacerbate symptoms. Stress movie with a peer group does not guarantee that
misperceptions about self, others and the world that management techniques can help the client reduce interaction will occur; therefore, the client may
impact functioning and contribute to symptoms. the psychological response to stress, which in turn remain isolated.
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PROFESSIONAL ADJUSTMENT in both government and private hospitals only voluntary and this right to join any organization is Answer: (A) BSN with at least 9 units of post graduate
D. Income tax which paid every March 15 and guaranteed in the 1987 constitution of the Philippines. studies in nursing administration
1. A nurse who would like to practice nursing in the professional tax which is paid every January 31. However, the PRC Code of Ethics states that one of the According to RA 9173 sec. 29, the educational
Philippines can obtain a license to practice by: ethical obligations of the professional nurse towards the qualification to be a supervisor in a hospital is at least 9
A. Paying the professional tax after taking the board Answer: (B) Income tax only since they are exempt from profession is to be an active member of the accredited units of postgraduate studies in nursing administration.
exams paying professional tax professional organization. A masters degree in nursing is required for the chief
B. Passing the board exams and taking the oath of According to the Magna Carta for Public Health Workers, nurse of a secondary or tertiary hospital.
professionals government nurses are exempted from paying 6. When the license of the nurse is revoked, it means
C. Paying the examination fee before taking the board professional tax. Hence, as an employee in the that the nurse: 9. The Board of Nursing has quasi-judicial power. An
exams government, s/he will pay only the income tax. A. Is no longer allowed to practice the profession for the example of this power is:
D. Undergoing the interview conducted by the Board of rest of her life A. The Board can issue rules and regulations that will
Nursing and taking the board exams 4. According to RA 9173 Philippine Nursing Act of 2002, a B. Will never have her/his license re-issued since it has govern the practice of nursing
graduate nurse who wants to take must licensure been revoked B. The Board can investigate violations of the nursing law
Answer: (B) Passing the board exams and taking the oath examination must comply with the following C. May apply for re-issuance of his/her license based on and code of ethics
of professionals qualifications: certain conditions stipulated in RA 9173 C. The Board can visit a school applying for a permit in
For a nurse to obtain a license to practice nursing in the A. At least 21 years old, graduate of BSN from a D. Will remain unable to practice professional nursing collaboration with CHED
Philippines, s/he must pass the board examinations and recognized school, and of good moral character D. The Board prepares the board examinations
then take the oath of professionals before the Board of B. At least 18 years old, graduate of BSN from a Answer: (C) May apply for re-issuance of his/her license
Nursing. recognized school and of good moral character based on certain conditions stipulated in RA 9173 Answer: (B) The Board can investigate violations of the
C. At least 18 years old, provided that when s/he passes RA 9173 sec. 24 states that for equity and justice, a nursing law and code of ethics
2. Reciprocity of license to practice requires that the the board exams, s/he must be at least 21 years old; BSN revoked license maybe re-issued provided that the Quasi-judicial power means that the Board of Nursing
country of origin of the interested foreign nurse graduate of a recognized school, and of good moral following conditions are met: a) the cause for revocation has the authority to investigate violations of the nursing
complies with the following conditions: character of license has already been corrected or removed; and, law and can issue summons, subpoena or subpoena
A. The country of origin has similar preparation for a D. Filipino citizen or a citizen of a country where we have b) at least four years has elapsed since the license has duces tecum as needed.
nurse and has laws allowing Filipino nurses to practice in reciprocity; graduate of BSN from a recognized school been revoked.
their country. and of good moral character 10. When a nurse causes an injury to the patient and the
B. The Philippines is recognized by the country of origin 7. According to the current nursing law, the minimum injury caused becomes the proof of the negligent act,
as one that has high quality of nursing education Answer: (D) Filipino citizen or a citizen of a country educational qualification for a faculty member of a the presence of the injury is said to exemplify the
C. The country of origin requires Filipinos to take their where we have reciprocity; graduate of BSN from a college of nursing is: principle of:
own board examination recognized school and of good moral character A. Only a Master of Arts in Nursing is acceptable A. Force majeure
D. The country of origin exempts Filipinos from passing RA 9173 section 13 states that the qualifications to take B. Masters degree in Nursing or in the related fields B. Respondeat superior
their licensure examination the board exams are: Filipino citizen or citizen of a C. At least a doctorate in nursing C. Res ipsa loquitur
country where the Philippines has reciprocity; of good D. At least 18 units in the Master of Arts in Nursing D. Holdover doctrine
Answer: (A) The country of origin has similar preparation moral character and graduate of BSN from a recognized Program
for a nurse and has laws allowing Filipino nurses to school of nursing. There is no explicit provision about the Answer: (C) Res ipsa loquitur
practice in their country. age requirement in RA 9173 unlike in RA7164 (old law). Answer: (B) Masters degree in Nursing or in the related Res ipsa loquitur literally means the thing speaks for
According to the Philippine Nurses Act of 2002, foreign fields itself. This means in operational terms that the injury
nurses wanting to practice in the Philippines must show 5. Which of the following is TRUE about membership to According to RA 9173 sec. 27, the educational caused is the proof that there was a negligent act.
proof that his/her country of origin meets the two the Philippine Nurses Association (PNA)? qualification of a faculty member teaching in a college of
essential conditions: a) the requirements for registration A. Membership to PNA is mandatory and is stipulated in nursing must be masters degree which maybe in nursing 11. Ensuring that there is an informed consent on the
between the two countries are substantially the same; the Philippine Nursing Act of 2002 or related fields like education, allied health professions, part of the patient before a surgery is done, illustrates
and b) the country of origin of the foreign nurse has laws B. Membership to PNA is compulsory for newly psychology. the bioethical principle of:
allowing the Filipino nurse to practice in his/her country registered nurses wanting to enter the practice of A. Beneficence
just like its own citizens. nursing in the country 8. The educational qualification of a nurse to become a B. Autonomy
C. Membership to PNA is voluntary and is encouraged by supervisor in a hospital is: C. Truth telling/veracity
3. Nurses practicing the profession in the Philippines and the PRC Code of Ethics for Nurses A. BSN with at least 9 units of post graduate studies in D. Non-maleficence
are employed in government hospitals are required to D. Membership to PNA is required by government nursing administration
pay taxes such as: hospitals prior to employment B. Master of Arts in Nursing major in administration Answer: (B) Autonomy
A. Both income tax and professional tax C. At least 2 years experience as a headnurse Informed consent means that the patient fully
B. Income tax only since they are exempt from paying Answer: (C) Membership to PNA is voluntary and is D. At least 18 units of post graduate studies in nursing understands what will be the surgery to be done, the
professional tax encouraged by the PRC Code of Ethics for Nurses administration risks involved and the alternative solutions so that when
C. Professional tax which is paid by all nurses employed Membership to any organization, including the PNA, is s/he give consent it is done with full knowledge and is
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given freely. The action of allowing the patient to decide not required to give extraordinary measures but cannot LEADERSHIP and MANAGEMENT 4. Which of the following conclusions of Ms. Castro
whether a surgery is to be done or not exemplifies the withhold the basic needs like food, water, and air. It also about leadership characteristics is TRUE?
bioethical principle of autonomy. means that the nurse is still duty bound to give the basic 1. Ms. Castro is newly-promoted to a patient care A. There is a high correlation between the
nursing care to the terminally ill patient and ensure that manager position. She updates her knowledge on the communication skills of a leader and the ability to get
12. When a nurse is providing care to her/his patient, the spiritual needs of the patient is taken cared of. theories in management and leadership in order to the job done.
s/he must remember that she is duty bound not to do become effective in her new role. She learns that some B. A manager is effective when he has the ability to plan
doing any action that will cause the patient harm. This is 15. Which of the following statements is TRUE of managers have low concern for services and high well.
the meaning of the bioethical principle: abortion in the Philippines? concern for staff. Which style of management refers to C. Assessment of personal traits is a reliable tool for
A. Non-maleficence A. Induced abortion is allowed in cases of rape and this? predicting a manager’s potential.
B. Beneficence incest A. Organization Man D. There is good evidence that certain personal qualities
C. Justice B. Induced abortion is both a criminal act and an B. Impoverished Management favor success in managerial role.
D. Solidarity unethical act for the nurse C. Country Club Management
C. Abortion maybe considered acceptable if the mother D. Team Management Answer: (C) Assessment of personal traits is a reliable
Answer: (A) Non-maleficence is unprepared for the pregnancy tool for predicting a manager’s potential.
Non-maleficence means do not cause harm or do any D. A nurse who performs induced abortion will have no Answer: (C) Country Club Management It is not conclusive that certain qualities of a person
action that will cause any harm to the patient/client. To legal accountability if the mother requested that the Country club management style puts concern for the would make him become a good manager. It can only
do good is referred as beneficence. abortion done on her. staff as number one priority at the expense of the predict a manager’s potential of becoming a good one.
delivery of services. He/she runs the department just like
13. When the patient is asked to testify in court, s/he Answer: (B) Induced abortion is both a criminal act and a country club where every one is happy including the 5. She reads about Path Goal theory. Which of the
must abide by the ethical principle of: an unethical act for the nurse manager. following behaviors is manifested by the leader who uses
A. Privileged communication Induced abortion is considered a criminal act which is this theory?
B. Informed consent punishable by imprisonment which maybe up to a 2. Her former manager demonstrated passion for serving A. Recognizes staff for going beyond expectations by
C. Solidarity maximum of 12 years if the nurse gets paid for it. Also, her staff rather than being served. She takes time to giving them citations
D. Autonomy the PRC Code of Ethics states that the nurse must listen, prefers to be a teacher first before being a leader, B. Challenges the staff to take individual accountability
respect life and must not do any action that will destroy which is characteristic of for their own practice
Answer: (A) Privileged communication life. Abortion is an act that destroys life albeit at the A. Transformational leader C. Admonishes staff for being laggards.
All confidential information that comes to the beginning of life. B. Transactional leader D. Reminds staff about the sanctions for non
knowledge of the nurse in the care of her/his patients is C. Servant leader performance.
considered privileged communications. Hence, s/he is D. Charismatic leader
not allowed to just reveal the confidential information Answer: (A) Recognizes staff for going beyond
arbitrarily. S/he may only be allowed to break the seal of Answer: (C) Servant leader expectations by giving them citations
secrecy in certain conditions. One such condition is when Servant leaders are open-minded, listen deeply, try to Path Goal theory according to House and associates
the court orders the nurse to testify in a criminal or fully understand others and not being judgmental rewards good performance so that others would do the
medico-legal case. same
3. On the other hand, Ms. Castro notices that the Chief
14. When the doctor orders “do not resuscitate”, this Nurse Executive has charismatic leadership style. Which 6. One leadership theory states that “leaders are born
means that of the following behaviors best describes this style? and not made,” which refers to which of the following
A. The nurse need not give due care to the patient since A. Possesses inspirational quality that makes followers theories?
s/he is terminally ill gets attracted of him and regards him with reverence A. Trait
B. The patient need not be given food and water after all B. Acts as he does because he expects that his behavior B. Charismatic
s/he is dying will yield positive results C. Great Man
C. The nurses and the attending physician should not do C. Uses visioning as the core of his leadership D. Situational
any heroic or extraordinary measures for the patient D. Matches his leadership style to the situation at hand.
D. The patient need not be given ordinary care so that Answer: (C) Great Man
her/his dying process is hastened Answer: (A) Possesses inspirational quality that makes Leaders become leaders because of their birth right. This
followers gets attracted of him and regards him with is also called Genetic theory or the Aristotelian theory
Answer: (C) The nurses and the attending physician reverence
should not do any heroic or extraordinary measures for Charismatic leaders make the followers feel at ease in 7. She came across a theory which states that the
the patient their presence. They feel that they are in good hands leadership style is effective dependent on the situation.
Do not resuscitate” is a medical order which is written whenever the leader is around. Which of the following styles best fits a situation when
on the chart after the doctor has consulted the family the followers are self-directed, experts and arematured
and this means that the members of the health team are individuals?
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A. Democratic their subordinates vote wins.1/2 + 1 is a majority. at the same time applies the management process of
B. Authoritarian Benevolent-authoritative managers pretentiously show planning, organizing, directing and controlling
C. Laissez faire their trust and confidence to their followers 14. One staff suggests that they review the pattern of
D. Bureaucratic nursing care that they are using, which is described as a 18. Which of the following is the best guarantee that the
11. Harry is a Unit Manager I the Medical Unit. He is not A. job description patient’s priority needs are met?
Answer: (C) Laissez faire satisfied with the way things are going in his unit. Patient B. system used to deliver care A. Checking with the relative of the patient
Laissez faire leadership is preferred when the followers satisfaction rate is 60% for two consecutive months and C. manual of procedure B. Preparing a nursing care plan in collaboration with the
know what to do and are experts in the field. This staff morale is at its lowest. He decides to plan and D. rules to be followed patient
leadership style is relationship-oriented rather than task- initiate changes that will push for a turnaround in the C. Consulting with the physician
centered. condition of the unit. Which of the following actions is a Answer: (B) system used to deliver care D. Coordinating with other members of the team
priority for Harry? A system used to deliver care. In the 70’s it was termed
8. She surfs the internet for more information about A. Call for a staff meeting and take this up in the agenda. as methods of patient assignment; in the early 80’s it Answer: (B) Preparing a nursing care plan in
leadership styles. She reads about shared leadership as a B. Seek help from her manager. was called modalities of patient care then patterns of collaboration with the patient
practice in some magnet hospitals. Which of the C. Develop a strategic action on how to deal with these nursing care in the 90’s until recently authors called it The best source of information about the priority needs
following describes this style of leadership? concerns. nursing care systems. of the patient is the patient himself. Hence using a
A. Leadership behavior is generally determined by the D. Ignore the issues since these will be resolved nursing care plan based on his expressed priority needs
relationship between the leader’s personality and the naturally. 15. Which of the following is TRUE about functional would ensure meeting his needs effectively.
specific situation nursing? 19. When Harry uses team nursing as a care delivery
B. Leaders believe that people are basically good and Answer: (A) Call for a staff meeting and take this up in A. Concentrates on tasks and activities system, he and his team need to assess the priority of
need not be closely controlled the agenda. B. Emphasizes use of group collaboration care for a group of patients, which of the following
C. Leaders rely heavily on visioning and inspire members This will allow for the participation of every staff in the C. One-to-one nurse-patient ratio should be a priority?
to achieve results unit. If they contribute to the solutions of the problem, D. Provides continuous, coordinated and comprehensive A. Each patient as listed on the worksheet
D. Leadership is shared at the point of care. they will own the solutions; hence the chance for nursing services B. Patients who needs least care
compliance would be greater. C. Medications and treatments required for all patients
Answer: (D) Leadership is shared at the point of care. Answer: (A) Concentrates on tasks and activities D. Patients who need the most care
Shared governance allows the staff nurses to have the 12. She knows that there are external forces that Functional nursing is focused on tasks and activities and
authority, responsibility and accountability for their own influence changes in his unit. Which of the following is not on the holistic care of the patients Answer: (D) Patients who need the most care
practice. NOT an external force? In setting priorities for a group of patients, those who
A. Memo from the CEO to cut down on electrical 16. Functional nursing has some advantages, which one need the most care should be number-one priority to
9. Ms. Castro learns that some leaders are transactional consumption is an EXCEPTION? ensure that their critical needs are met adequately. The
leaders. Which of the following does NOT characterize a B. Demands of the labor sector to increase wages A. Psychological and sociological needs are emphasized. needs of other patients who need less care ca be
transactional leader? C. Low morale of staff in her unit B. Great control of work activities. attended to later or even delegated to assistive
A. Focuses on management tasks D. Exacting regulatory and accreditation standards C. Most economical way of delivering nursing services. personnel according to rules on delegation.
B. Is a caretaker D. Workers feel secure in dependent role
C. Uses trade-offs to meet goals Answer: (C) Low morale of staff in her unit 20. She is hopeful that her unit will make a big
D. Inspires others with vision Low morale of staff is an internal factor that affects only Answer: (A) Psychological and sociological needs are turnaround in the succeeding months. Which of the
the unit. All the rest of the options emanate from the emphasized. following actions of Harry demonstrates that he has
Answer: (D) Inspires others with vision top executive or from outside the institution. When the functional method is used, the psychological reached the third stage of change?
Inspires others with a vision is characteristic of a and sociological needs of the patients are neglected; the A. Wonders why things are not what it used to be
transformational leader. He is focused more on the day- 13. After discussing the possible effects of the low patients are regarded as ‘tasks to be done ‘ B. Finds solutions to the problems
to-day operations of the department/unit. patient satisfaction rate, the staff started to list down C. Integrate the solutions to his day-to-day activities
possible strategies to solve the problems head-on. 17. He raised the issue on giving priority to patient D. Selects the best change strategy
10. She finds out that some managers have benevolent- Should they decide to vote on the best change strategy, needs. Which of the following offers the best way for
authoritative style of management. Which of the which of the following strategies is referred to this? setting priority? Answer: (C) Integrate the solutions to his day-to-day
following behaviors will she exhibit most likely? A. Collaboration A. Assessing nursing needs and problems activities
A. Have condescending trust and confidence in their B. Majority rule B. Giving instructions on how nursing care needs are to Integrate the solutions to his day-to-day activities is a
subordinates C. Dominance be met expected to happen during the third stage of change
B. Gives economic or ego awards D. Compromise C. Controlling and evaluating the delivery of nursing care when the change agent incorporate the selected
C. Communicates downward to the staff D. Assigning safe nurse: patient ratio solutions to his system and begins to create a change.
D. Allows decision making among subordinates Answer: (B) Majority rule
Majority rule involves dividing the house and the highest Answer: (A) Assessing nursing needs and problems 21. Julius is a newly-appointed nurse manager of The
Answer: (A) Have condescending trust and confidence in This option follows the framework of the nursing process Good Shepherd Medical Center, a tertiary hospital
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located within the heart of the metropolis. He thinks of Answer: (C) Broken line A. “Let’s work together in harmony; we need to be Answer: (A) Proactive and caring with one another
scheduling planning workshop with his staff in order to This is a staff relationship hence it is depicted by a supportive of one another” Positive culture is based on humanism and affiliative
ensure an effective and efficient management of the broken line in the organizational structure B. “In order that we achieve the same results; we must norms
department. Should he decide to conduct a strategic all follow the directives of Julius and not from other
planning workshop, which of the following is NOT a 25. He likewise stresses the need for all the employees managers.” 32. Stephanie is a new Staff Educator of a private tertiary
characteristic of this activity? to follow orders and instructions from him and not from C. “We will ensure that all the resources we need are hospital. She conducts orientation among new staff
A. Long-term goal-setting anyone else. Which of the following principles does he available when needed.” nurses in her department. Joseph, one of the new staff
B. Extends to 3-5 years in the future refer to? D. “We need to put our efforts together in order to raise nurses, wants to understand the channel of
C. Focuses on routine tasks A. Scalar chain the bar of excellence in the care we provide to all our communication, span of control and lines of
D. Determines directions of the organization B. Discipline patients.” communication. Which of the following will provide this
C. Unity of command information?
Answer: (C) Focuses on routine tasks D. Order Answer: (A) “Let’s work together in harmony; we need A. Organizational structure
Strategic planning involves options A, B and D except C to be supportive of one another” B. Policy
which is attributed to operational planning Answer: (C) Unity of command The principle of ‘esprit d’ corps’ refers to promoting C. Job description
22. Which of the following statements refer to the vision The principle of unity of command means that harmony in the workplace, which is essential in D. Manual of procedures
of the hospital? employees should receive orders coming from only one maintaining a climate conducive to work.
A. The Good Shepherd Medical Center is a trendsetter in manager and not from two managers. This averts the Answer: (A) Organizational structure
tertiary health care in the Philippines in the next five possibility of sowing confusion among the members of 29. He discusses the goal of the department. Which of Organizational structure provides information on the
years the organization the following statements is a goal? channel of authority, i.e., who reports to whom and with
B. The officers and staff of The Good Shepherd Medical A. Increase the patient satisfaction rate what authority; the number of people who directly
Center believe in the unique nature of the human person 26. Julius orients his staff on the patterns of reporting B. Eliminate the incidence of delayed administration of reports to the various levels of hierarchy and the lines of
C. All the nurses shall undergo continuing competency relationship throughout the organization. Which of the medications communication whether line or staff.
training program. following principles refer to this? C. Establish rapport with patients.
D. The Good Shepherd Medical Center aims to provide a A. Span of control D. Reduce response time to two minutes. 33. Stephanie is often seen interacting with the medical
patient-centered care in a total healing environment. B. Hierarchy intern during coffee breaks and after duty hours. What
C. Esprit d’ corps Answer: (A) Increase the patient satisfaction rate type of organizational structure is this?
Answer: (A) The Good Shepherd Medical Center is a D. Unity of direction Goal is a desired result towards which efforts are A. Formal
trendsetter in tertiary health care in the Philippines in directed. Options AB, C and D are all objectives which B. Informal
the next five years Answer: (B) Hierarchy are aimed at specific end. C. Staff
A vision refers to what the institution wants to become Hierarchy refers to the pattern of reporting or the formal D. Line
within a particular period of time. line of authority in an organizational structure. 30. He wants to influence the customary way of thinking
and behaving that is shared by the members of the Answer: (B) Informal
23. The statement, “The Good Shepherd Medical Center 27. He emphasizes to the team that they need to put department. Which of the following terms refer to this? This is usually not published and oftentimes concealed.
aims to provide patient-centered care in a total healing their efforts together towards the attainment of the A. Organizational chart
environment” refers to which of the following? goals of the program. Which of the following principles B. Cultural network 34. She takes pride in saying that the hospital has a
A. Vision refers to this? C. Organizational structure decentralized structure. Which of the following is NOT
B. Goal A. Span of control D. Organizational culture compatible with this type of model?
C. Philosophy B. Unity of direction A. Flat organization
D. Mission C. Unity of command Answer: (D) Organizational culture B. Participatory approach
D. Command responsibility An organizational culture refers to the way the members C. Shared governance
Answer: (B) Goal of the organization think together and do things around D. Tall organization
Answer: (B) Unity of direction them together. It’s their way of life in that organization
24. Julius plans to revisit the organizational chart of the Unity of direction means having one goal or one Answer: (D) Tall organization
department. He plans to create a new position of a objective for the team to pursue; hence all members of 31. He asserts the importance of promoting a positive Tall organizations are highly centralized organizations
Patient Educator who has a coordinating relationship the organization should put their efforts together organizational culture in their unit. Which of the where decision making is centered on one authority
with the head nurse in the unit. Which of the following towards the attainment of their common goal or following behaviors indicate that this is attained by the level.
will likely depict this organizational relationship? objective. group?
A. Box A. Proactive and caring with one another 35. Centralized organizations have some advantages.
B. Solid line 28. Julius stresses the importance of promoting ‘esprit d B. Competitive and perfectionist Which of the following statements are TRUE?
C. Broken line corps’ among the members of the unit. Which of the C. Powerful and oppositional 1. Highly cost-effective
D. Dotted line following remarks of the staff indicates that they D. Obedient and uncomplaining 2. Makes management easier
understand what he pointed out? 3. Reflects the interest of the worker
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4. Allows quick decisions or actions. A. Uses visioning as the essence of leadership. Answer: (B) Is not beneficial; hence it should be Performance appraisal deal with both positive and
B. Serves the followers rather than being served. prevented at all times negative performance; is not meant to be a fault-finding
A. 1 & 2 C. Maintains full trust and confidence in the Conflicts are beneficial because it surfaces out issues in activity
B. 2 & 4 subordinates the open and can be solved right away. Likewise,
C. 2, 3& 4 D. Possesses innate charisma that makes others feel members of the team become more conscientious with 46. Which of the following statements is NOT true about
D. 1, 2, & 4 good in his presence. their work when they are aware that other members of performance appraisal?
the team are watching them. A. Informing the staff about the specific impressions of
Answer: (A) 1 & 2 Answer: (A) Uses visioning as the essence of leadership. their work help improve their performance.
Centralized organizations are needs only a few managers Transformational leadership relies heavily on visioning as 43. Katherine tells one of the staff, “I don’t have time to B. A verbal appraisal is an acceptable substitute for a
hence they are less expensive and easier to manage the core of leadership. discuss the matter with you now. See me in my office written report
later” when the latter asks if they can talk about an C. Patients are the best source of information regarding
36. Stephanie delegates effectively if she has authority 40. As a manager, she focuses her energy on both the issue. Which of the following conflict resolution personnel appraisal.
to act, which is BEST defined as: quality of services rendered to the patients as well as the strategies did she use? D. The outcome of performance appraisal rests primarily
A. having responsibility to direct others welfare of the staff of her unit. Which of the following A. Smoothing with the staff.
B. being accountable to the organization management styles does she adopt? B. Compromise
C. having legitimate right to act A. Country club management C. Avoidance Answer: (C) Patients are the best source of information
D. telling others what to do B. Organization man management D. Restriction regarding personnel appraisal.
C. Team management The patient can be a source of information about the
Answer: (C) having legitimate right to act D. Authority-obedience management Answer: (C) Avoidance performance of the staff but it is never the best source.
Authority is a legitimate or official right to give This strategy shuns discussing the issue head-on and Directly observing the staff is the best source of
command. This is an officially sanctioned responsibility Answer: (C) Team management prefers to postpone it to a later time. In effect the information for personnel appraisal.
Team management has a high concern for services and problem remains unsolved and both parties are in a lose-
37. Regardless of the size of a work group, enough staff high concern for staff. lose situation. 47. There are times when Katherine evaluates her staff
must be available at all times to accomplish certain as she makes her daily rounds. Which of the following is
purposes. Which of these purposes in NOT included? 41. Katherine is a young Unit Manager of the Pediatric 44. Kathleen knows that one of her staff is experiencing NOT a benefit of conducting an informal appraisal?
A. Meet the needs of patients Ward. Most of her staff nurses are senior to her, very burnout. Which of the following is the best thing for her A. The staff member is observed in natural setting.
B. Provide a pair of hands to other units as needed articulate, confident and sometimes aggressive. to do? B. Incidental confrontation and collaboration is allowed.
C. Cover all time periods adequately. Katherine feels uncomfortable believing that she is the A. Advise her staff to go on vacation. C. The evaluation is focused on objective data
D. Allow for growth and development of nursing staff. scapegoat of everything that goes wrong in her B. Ignore her observations; it will be resolved even systematically.
department. Which of the following is the best action without intervention D. The evaluation may provide valid information for
Answer: (B) Provide a pair of hands to other units as that she must take? C. Remind her to show loyalty to the institution. compilation of a formal report.
needed A. Identify the source of the conflict and understand the D. Let the staff ventilate her feelings and ask how she
Providing a pair of hands for other units is not a purpose points of friction can be of help. Answer: (C) The evaluation is focused on objective data
in doing an effective staffing process. This is a function of B. Disregard what she feels and continue to work systematically.
a staffing coordinator at a centralized model. independently Answer: (D) Let the staff ventilate her feelings and ask Collecting objective data systematically can not be
C. Seek help from the Director of Nursing how she can be of help. achieved in an informal appraisal. It is focused on what
38. Which of the following guidelines should be least D. Quit her job and look for another employment. Reaching out and helping the staff is the most effective actually happens in the natural work setting.
considered in formulating objectives for nursing care? strategy in dealing with burn out. Knowing that someone
A. Written nursing care plan Answer: (A) Identify the source of the conflict and is ready to help makes the staff feel important; hence 48. She conducts a 6-month performance review session
B. Holistic approach understand the points of friction her self-worth is enhanced. with a staff member. Which of the following actions is
C. Prescribed standards This involves a problem solving approach, which appropriate?
D. Staff preferences addresses the root cause of the problem. 45. She knows that performance appraisal consists of all A. She asks another nurse to attest the session as a
the following activities EXCEPT: witness.
Answer: (D) Staff preferences 42. As a young manager, she knows that conflict occurs A. Setting specific standards and activities for individual B. She informs the staff that she may ask another nurse
Staff preferences should be the least priority in in any organization. Which of the following statements performance. to read the appraisal before the session is over.
formulating objectives of nursing care. Individual regarding conflict is NOT true? B. Using agency standards as a guide. C. She tells the staff that the session is manager-
preferences should be subordinate to the interest of the A. Can be destructive if the level is too high C. Determine areas of strength and weaknesses centered.
patients. B. Is not beneficial; hence it should be prevented at all D. Focusing activity on the correction of identified D. The session is private between the two members.
times behavior.
39. Stephanie considers shifting to transformational C. May result in poor performance Answer: (D) The session is private between the two
leadership. Which of the following statements best D. May create leaders Answer: (D) Focusing activity on the correction of members.
describes this type of leadership? identified behavior. The session is private between the manager and the
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staff and remains to be so when the two parties do not C. Membership to accredited professional organization C. Compatible with computerization D. Measure actual performances
divulge the information to others. D. Professional identification card D. Promotes better interpersonal relationship
Answer: (B) Identify the values of the department
49. Alexandra is tasked to organize the new wing of the Answer: (B) Record of related learning experience (RLE) Answer: (D) Promotes better interpersonal relationship Identify the values of the department will set the guiding
hospital. She was given the authority to do as she deems Record of RLE is not required for employment purposes Decentralized structures allow the staff to solve principles within which the department will operate its
fit. She is aware that the director of nursing has but it is required for the nurse’s licensure examination. decisions by themselves, involve them in decision activities
substantial trust and confidence in her capabilities, making; hence they are always given opportunities to
communicates through downward and upward channels 53. Which phase of the employment process includes interact with one another. 60. Ms. Valencia develops the standards to be followed.
and usually uses the ideas and opinions of her staff. getting on the payroll and completing documentary Among the following standards, which is considered as a
Which of the following is her style of management? requirements? 57. Aubrey thinks about primary nursing as a system to structure standard?
A. Benevolent –authoritative A. Orientation deliver care. Which of the following activities is NOT A. The patients verbalized satisfaction of the nursing
B. Consultative B. Induction done by a primary nurse? care received
C. Exploitive-authoritative C. Selection A. Collaborates with the physician B. Rotation of duty will be done every four weeks for all
D. Participative D. Recruitment B. Provides care to a group of patients together with a patient care personnel.
group of nurses C. All patients shall have their weights taken recorded
Answer: (B) Consultative Answer: (B) Induction C. Provides care for 5-6 patients during their hospital D. Patients shall answer the evaluation form before
A consultative manager is almost like a participative This step in the recruitment process gives time for the stay. discharge
manager. The participative manager has complete trust staff to submit all the documentary requirements for D. Performs comprehensive initial assessment
and confidence in the subordinate, always uses the employment. Answer: (B) Rotation of duty will be done every four
opinions and ideas of subordinates and communicates in Answer: (B) Provides care to a group of patients together weeks for all patient care personnel.
all directions. 54. She tries to design an organizational structure that with a group of nurses Structure standards include management system,
allows communication to flow in all directions and This function is done in team nursing where the nurse is facilities, equipment, materials needed to deliver care to
52. She decides to illustrate the organizational structure. involve workers in decision making. Which form of a member of a team that provides care for a group of patients. Rotation of duty is a management system.
Which of the following elements is NOT included? organizational structure is this? patients.
A. Level of authority A. Centralized 61. When she presents the nursing procedures to be
B. Lines of communication B. Decentralized 58. Which pattern of nursing care involves the care given followed, she refers to what type of standards?
C. Span of control C. Matrix by a group of paraprofessional workers led by a A. Process
D. Unity of direction D. Informal professional nurse who take care of patients with the B. Outcome
same disease conditions and are located geographically C. Structure
Answer: (D) Unity of direction Answer: (B) Decentralized near each other? D. Criteria
Unity of direction is a management principle, not an Decentralized structures allow the staff to make A. Case method
element of an organizational structure. decisions on matters pertaining to their practice and B. Modular nursing Answer: (A) Process
communicate in downward, upward, lateral and C. Nursing case management Process standards include care plans, nursing procedure
51. She plans of assigning competent people to fill the diagonal flow. D. Team nursing to be done to address the needs of the patients.
roles designed in the hierarchy. Which process refers to
this? 55. In a horizontal chart, the lowest level worker is Answer: (B) Modular nursing 62. The following are basic steps in the controlling
A. Staffing located at the Modular nursing is a variant of team nursing. The process of the department. Which of the following is
B. Scheduling A. Leftmost box difference lies in the fact that the members in modular NOT included?
C. Recruitment B. Middle nursing are paraprofessional workers. A. Measure actual performance
D. Induction C. Rightmost box B. Set nursing standards and criteria
D. Bottom 59. St. Raphael Medical Center just opened its new C. Compare results of performance to standards and
Answer: (A) Staffing Performance Improvement Department. Ms. Valencia is objectives
Staffing is a management function involving putting the Answer: (C) Rightmost box appointed as the Quality Control Officer. She commits D. Identify possible courses of action
best people to accomplish tasks and activities to attain The leftmost box is occupied by the highest authority herself to her new role and plans her strategies to realize
the goals of the organization. while the lowest level worker occupies the rightmost the goals and objectives of the department. Which of the Answer: (D) Identify possible courses of action
box. following is a primary task that they should perform to This is a step in a quality control process and not a basic
have an effective control system? step in the control process.
52. She checks the documentary requirements for the 56. She decides to have a decentralized staffing system. A. Make an interpretation about strengths and
applicants for staff nurse position. Which one is NOT Which of the following is an advantage of this system of weaknesses 63. Which of the following statements refers to criteria?
necessary? staffing? B. Identify the values of the department A. Agreed on level of nursing care
A. Certificate of previous employment A. greater control of activities C. Identify structure, process, outcome standards & B. Characteristics used to measure the level of nursing
B. Record of related learning experience (RLE) B. Conserves time criteria care
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C. Step-by-step guidelines B. Unity of command NURSING RESEARCH Part 1 D. “Environmental Manipulation and Client Outcomes”
D. Statement which guide the group in decision making C. Carrot and stick principle
and problem solving D. Esprit d’ corps 1. Kevin is a member of the Nursing Research Council of Answer: (B) “Turnaround Time in Emergency Rooms”
the hospital. His first assignment is to determine the The article is for pediatric patients and may not be
Answer: (B) Characteristics used to measure the level of Answer: (A) Span of control level of patient satisfaction on the care they received relevant for adult patients.
nursing care Span of control refers to the number of workers who from the hospital. He plans to include all adult patients
Criteria are specific characteristics used to measure the report directly to a manager. admitted from April to May, with average length of stay 5. Which of the following variables will he likely EXCLUDE
standard of care. of 3-4 days, first admission, and with no complications. in his study?
68. She notes that there is an increasing unrest of the Which of the following is an extraneous variable of the A. Competence of nurses
64. She wants to ensure that every task is carried out as staff due to fatigue brought about by shortage of staff. study? B. Caring attitude of nurses
planned. Which of the following tasks is NOT included in Which action is a priority? A. Date of admission C. Salary of nurses
the controlling process? A. Evaluate the overall result of the unrest B. Length of stay D. Responsiveness of staff
A. Instructing the members of the standards committee B. Initiate a group interaction C. Age of patients
to prepare policies C. Develop a plan and implement it D. Absence of complications Answer: (C) Salary of nurses
B. Reviewing the existing policies of the hospital D. Identify external and internal forces. Salary of staff nurses is not an indicator of patient
C. Evaluating the credentials of all nursing staff Answer: (C) Age of patients satisfaction, hence need not be included as a variable in
D. Checking if activities conform to schedule Answer: (B) Initiate a group interaction An extraneous variable is not the primary concern of the the study.
Initiate a group interaction will be an opportunity to researcher but has an effect on the results of the study.
Answer: (A) Instructing the members of the standards discuss the problem in the open. Adult patients may be young, middle or late adult. 6. He plans to use a Likert Scale to determine
committee to prepare policies A. degree of agreement and disagreement
Instructing the members involves a directing function. 2. He thinks of an appropriate theoretical framework. B. compliance to expected standards
Whose theory addresses the four modes of adaptation? C. level of satisfaction
65. Ms. Valencia prepares the process standards. Which A. Martha Rogers D. degree of acceptance
of the following is NOT a process standard? B. Sr. Callista Roy
A. Initial assessment shall be done to all patients within C. Florence Nightingale Answer: (A) degree of agreement and disagreement
twenty four hours upon admission. D. Jean Watson Likert scale is a 5-point summated scale used to
B. Informed consent shall be secured prior to any determine the degree of agreement or disagreement of
invasive procedure Answer: (B) Sr. Callista Roy the respondents to a statement in a study.
C. Patients’ reports 95% satisfaction rate prior to Sr. Callista Roy developed the Adaptation Model which
discharge from the hospital. involves the physiologic mode, self-concept mode, role 7. He checks if his instruments meet the criteria for
D. Patient education about their illness and treatment function mode and dependence mode evaluation. Which of the following criteria refers to the
shall be provided for all patients and their families. consistency or the ability to yield the same response
3. He opts to use a self-report method. Which of the upon its repeated administration?
Answer: (C) Patients’ reports 95% satisfaction rate prior following is NOT TRUE about this method? A. Validity
to discharge from the hospital. A. Most direct means of gathering information B. Reliability
This refers to an outcome standard, which is a result of B. Versatile in terms of content coverage C. Sensitivity
the care that is rendered to the patient. C. Most accurate and valid method of data gathering D. Objectivity
D. Yields information that would be difficult to gather by
66. Which of the following is evidence that the another method Answer: (B) Reliability
controlling process is effective? Reliability is repeatability of the instrument; it can elicit
A. The things that were planned are done Answer: (C) Most accurate and valid method of data the same responses even with varied administration of
B. Physicians do not complain. gathering the instrument
C. Employees are contended The most serious disadvantage of this method is
D. There is an increase in customer satisfaction rate. accuracy and validity of information gathered 8. Which criteria refer to the ability of the instrument to
detect fine differences among the subjects being
Answer: (A) The things that were planned are done 4. Which of the following articles would Kevin least studied?
Controlling is defined as seeing to it that what is planned consider for his review of literature? A. Sensitivity
is done. A. “Story-Telling and Anxiety Reduction Among Pediatric B. Reliability
Patients” C. Validity
67. Ms. Valencia is responsible to the number of B. “Turnaround Time in Emergency Rooms” D. Objectivity
personnel reporting to her. This principle refers to: C. “Outcome Standards in Tertiary Health Care
A. Span of control Institutions” Answer: (A) Sensitivity
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Sensitivity is an attribute of the instrument that allow transcultural theory based on her observations on the referred to as 20. Which of the following titles of the study is
the respondents to distinguish differences of the options behavior of selected people within a culture A. Bias appropriate for this study?
where to choose from B. Hawthorne effect A. Lived Experiences of Terminally-Ill Cancer Patients
13. Which of the following statements best describes a C. Halo effect B. Coping Skills of Terminally-Ill Cancer Patients in a
9. Which of the following terms refer to the degree to phenomenological study? D. Horns effect Selected Hospital
which an instrument measures what it is supposed to be A. Involves the description and interpretation of cultural C. Two Case Studies of Terminally-Ill Patients in Manila
measure? behavior Answer: (B) Hawthorne effect D. Beliefs & Practices of Patients with Terminal Cancer
A. Validity B. Focuses on the meaning of experiences as those who Hawthorne effect is based on the study of Elton Mayo
B. Reliability experience it and company about the effect of an intervention done to Answer: (B) Coping Skills of Terminally-Ill Cancer Patients
C. Meaningfulness C. Involves an in-depth study of an individual or group improve the working conditions of the workers on their in a Selected Hospital
D. Sensitivity D. Involves collecting and analyzing data that aims to productivity. It resulted to an increased productivity but The title has a specific phenomenon, sample and
develop theories grounded in real-world observations not due to the intervention but due to the psychological research locale.
Answer: (A) Validity effects of being observed. They performed differently
Validity is ensuring that the instrument contains Answer: (B) Focuses on the meaning of experiences as because they were under observation. 21. Ms. Montana plans to conduct a research on the use
appropriate questions about the research topic those who experience it of a new method of pain assessment scale. Which of the
Phenomenological study involves understanding the 17. Which of the following items refer to the sense of following is the second step in the conceptualizing phase
10. He plans for his sampling method. Which sampling meaning of experiences as those who experienced the closure that Raphael experiences when data collection of the research process?
method gives equal chance to all units in the population phenomenon. ceases to yield any new information? A. Formulating the research hypothesis
to get picked? A. Saturation B. Review related literature
A. Random 14. He systematically plans his sampling plan. Should he B. Precision C. Formulating and delimiting the research problem
B. Accidental decides to include whoever patients are admitted during C. Limitation D. Design the theoretical and conceptual framework
C. Quota the study he uses what sampling method? D. Relevance
D. Judgment A. Judgment Answer: (B) Review related literature
B. Accidental Answer: (A) Saturation After formulating and delimiting the research problem,
Answer: (A) Random C. Random Saturation is achieved when the investigator can not the researcher conducts a review of related literature to
Random sampling gives equal chance for all the D. Quota extract new responses from the informants, but instead, determine the extent of what has been done on the
elements in the population to be picked as part of the gets the same responses repeatedly. study by previous researchers.
sample. Answer: (B) Accidental
Accidental sampling is a non-probability sampling 18. In qualitative research the actual analysis of data 22. Which of the following codes of research ethics
11. Raphael is interested to learn more about method which includes those who are at the site during begins with: requires informed consent in all cases governing human
transcultural nursing because he is assigned at the family data collection. A. search for themes subjects?
suites where most patients come from different cultures B. validation of thematic analysis A. Helsinki Declaration
and countries. Which of the following designs is 15. He finally decides to use judgment sampling. Which C. weave the thematic strands together B. Nuremberg Code
appropriate for this study? of the following actions of Raphael is correct? D. quasi statistics C. Belmont Report
A. Grounded theory A. Plans to include whoever is there during his study. D. ICN Code of Ethics
B. Ethnography B. Determines the different nationality of patients Answer: (A) search for themes
C. Case study frequently admitted and decides to get representations The investigator starts data analysis by looking for Answer: (A) Helsinki Declaration
D. Phenomenology samples from each. themes from the verbatim responses of the informants. Helsinki Declaration is the first international attempt to
C. Assigns numbers for each of the patients, place these set up ethical standards in research involving human
Answer: (B) Ethnography in a fishbowl and draw 10 from it. 19. Raphael is also interested to know the coping research subjects.
Ethnography is focused on patterns of behavior of D. Decides to get 20 samples from the admitted patients abilities of patients who are newly diagnosed to have
selected people within a culture terminal cancer. Which of the following types of 23. Which of the following ethical principles was NOT
Answer: (B) Determines the different nationality of research is appropriate? articulated in the Belmont Report?
12. The nursing theorist who developed transcultural patients frequently admitted and decides to get A. Phenomenological A. Beneficence
nursing theory is representations samples from each. B. Ethnographic B. Respect for human dignity
A. Dorothea Orem Judgment sampling involves including samples according C. Grounded Theory C. Justice
B. Madeleine Leininger to the knowledge of the investigator about the D. Case Study D. Non-maleficence
C. Betty Newman participants in the study.
D. Sr. Callista Roy Answer: (C) Grounded Theory Answer: (D) Non-maleficence
16. He knows that certain patients who are in a Grounded theory inductively develops a theory based on Non-maleficence is not articulated in the Belmont
Answer: (B) Madeleine Leininger specialized research setting tend to respond the observed processes involving selected people Report. It only includes beneficence, respect for human
Madeleine Leininger developed the theory on psychologically to the conditions of the study. This is
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dignity and justice. rejected. Hypothesis is testable and is defined as a C. analysis A. CINAHL
statement that predicts the relationship between D. conclusion B. MEDLINE
24. Which one of the following criteria should be variables C. HealthSTAR
considered as a top priority in nursing care? Answer: (B) interpretation D. EMBASE
A. Avoidance of destructive changes 28. Which of the following measures will best prevent Interpretation includes the inferences of the researcher
B. Preservation of life manipulation of vulnerable groups? about the findings of the study. Answer: (A) CINAHL
C. Assurance of safety A. Secure informed consent This refers to Cumulative Index to Nursing and Allied
D. Preservation of integrity B. Payment of stipends for subjects 32. The study is said to be completed when Ms. Health Literature which is a rich source for literature
C. Protect privacy of patient Montana achieved which of the following activities? review for nurses. The rest of the sites are for medicine,
Answer: (B) Preservation of life D. Ensure confidentiality of data A. Published the results in a nursing journal. pharmacy and other health-related sites.
The preservation of life at all cost is a primary B. Presented the study in a research forum.
responsibility of the nurse. This is embodied in the Code Answer: (A) Secure informed consent C. The results of the study is used by the nurses in the 36. While reviewing journal articles, Stephanie got
of Ethics for registered nurses ( BON Resolution 220 s. Securing informed consent will free the researcher from hospital interested in reading the brief summary of the article
2004). being accused of manipulating the subjects because by D. Submitted the research report to the CEO. placed at the beginning of the journal report. Which of
so doing he/she gives ample opportunity for the subjects the following refers to this?
25. Which of the following procedures ensures that the to weigh the advantages/disadvantages of being Answer: (C) The results of the study is used by the nurses A. Introduction
investigator has fully described to prospective subjects included in the study prior to giving his consent. This is in the hospital B. Preface
the nature of the study and the subject's rights? done without any element of force, coercion, threat or The last step in the research process is the utilization of C. Abstract
A. Debriefing even inducement. the research findings. D. Background
B. Full disclosure
C. Informed consent 29. Which of the following procedures ensures that Ms. 33. Situation: Stephanie is a nurse researcher of the Answer: (C) Abstract
D. Cover data collection Montana has fully described to prospective subjects the Patient Care Services Division. She plans to conduct a Abstract contains concise description of the background
nature of the study and the subject’s rights? literature search for her study. of the study, research questions, research objectives,
Answer: (B) Full disclosure A. Debriefing methods, findings, implications to nursing practice as
Full disclosure is giving the subjects of the research B. Full disclosure Which of the following is the first step in selecting well as keywords used in the study.
information that they deserve to know prior to the C. Informed consent appropriate materials for her review?
conduct of the study. D. Covert data collection A. Track down most of the relevant resources 37. She notes down ideas that were derived from the
B. Copy relevant materials description of an investigation written by the person
26. After the review session has been completed, Karen Answer: (B) Full disclosure C. Organize materials according to function who conducted it. Which type of reference source refers
and the staff signed the document. Which of the Full disclosure is giving the subjects of the research D. Synthesize literature gathered. to this?
following is the purpose of this? information that they deserve to know prior to the A. Footnote
A. Agree about the content of the evaluation. conduct of the study Answer: (A) Track down most of the relevant resources B. Bibliography
B. Signify disagreement of the content of the evaluation. The first step in the review of related literature is to C. Primary source
C. Document that Karen and the staff reviewed the 30. This technique refers to the use of multiple referents track down relevant sources before copying these. The D. Endnotes
evaluation. to draw conclusions about what constitutes the truth last step is to synthesize the literature gathered.
D. Serve as basis for future evaluation. A. Triangulation Answer: (C) Primary source
B. Experiment 34. She knows that the most important categories of This refers to a primary source which is a direct account
Answer: (C) Document that Karen and the staff reviewed C. Meta-analysis information in literature review is the: of the investigation done by the investigator. In contrast
the evaluation. D. Delphi technique A. research findings to this is a secondary source, which is written by
Signing the document is done to serve as a proof that B. theoretical framework someone other than the original researcher.
performance review was conducted during that date and Answer: (A) Triangulation C. methodology
time. Triangulation makes use of different sources of D. opinions 38. She came across a study which is referred to as
information such as triangulation in design, researcher meta-analysis. Which of the following statements best
27. Which of the following is NOT true about a and instrument. Answer: (A) research findings defines this type of study?
hypothesis? Hypothesis is: The research findings is the most important category of A. Treats the findings from one study as a single piece of
A. testable 31. The statement, “Ninety percent (90%) of the information that the researcher should copy because data
B. proven respondents are female staff nurses validates previous this will give her valuable information as to what has B. Findings from multiple studies are combined to yield a
C. stated in a form that it can be accepted or rejected research findings (Santos, 2001; Reyes, 2005) that the been discovered in past studies about the same topic. data set which is analyzed as individual data
D. states a relationship between variables nursing profession is largely a female dominated C. Represents an application of statistical procedures to
profession is an example of 35. She also considers accessing electronic data bases for findings from each report
Answer: (B) proven A. implication her literature review. Which of the following is the most D. Technique for quantitatively combining and thus
Hypothesis is not proven; it is either accepted or B. interpretation useful electronic database for nurses? integrating the results of multiple studies on a given
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topic. difference or no relationship between the variables in A. Clearly identified the variables/phenomenon under Answer: (C) Determine the budgetary allocation for the
the study consideration. study
Answer: (D) Technique for quantitatively combining and B. Specifies the population being studied. Determining budgetary allocation for the study is not a
thus integrating the results of multiple studies on a given 42. She notes that the dependent variable in the C. Implies the feasibility of empirical testing purpose of doing a pretesting of the instruments. This is
topic. hypothesis “Duration of sleep of cuddled infants is D. Indicates the hypothesis to be tested. done at an earlier stage of the design and planning
Though all the options are correct, the best definition is longer than those infants who are not cuddled by phase.
option D because it combines quantitatively the results mothers” is Answer: (D) Indicates the hypothesis to be tested.
and at the same time it integrates the results of the A. Cuddled infants Not all studies require a hypothesis such as qualitative 50. She tests the instrument whether it looks as though
different studies as one finding. B. Duration of sleep studies, which does not deal with variables but with it is measuring appropriate constructs. Which of the
C. Infants phenomenon or concepts. following refers to this?
39. This kind of research gathers data in detail about a D. Absence of cuddling A. Face validity
individual or groups and presented in narrative form, 47. She states the purposes of the study. Which of the B. Content validity
which is Answer: (B) Duration of sleep following describe the purpose of a study? C. Construct Validity
A. Case study Duration of sleep is the ‘effect’ (dependent variable) of D. Criterion-related validity
B. Historical cuddling ‘cause’ (independent variable). 1. Establishes the general direction of a study
C. Analytical 2. Captures the essence of the study Answer: (A) Face validity
D. Experimental 43. Situation: Aretha is a nurse researcher in a tertiary 3. Formally articulates the goals of the study Face validity measures whether the instrument appears
hospital. She is tasked to conduct a research on the 4. Sometimes worded as an intent to be measuring the appropriate construct. It is the
Answer: (A) Case study effects of structured discharge plan for post-open heart A. 1, 2, 3 easiest type of validity testing.
Case study focuses on in-depth investigations of single surgery patients. B. 2, 3, 4
entity or small number of entities. It attempts to analyze C. 1, 3, 4 51. Which of the following questions would determine
and understand issues of importance to history, She states the significance of the research problem. D. 1, 2, 3, 4 the construct validity of the instrument?
development or circumstances of the person or entity Which of the following statements is the MOST A. “What is this instrument really measuring?”
under study. significant for this study? Answer: (D) 1, 2, 3, 4 B. “How representative are the questions on this test of
A. Improvement in patient care The purposes of a research study covers all the options the universe of questions on this topic?”
40. Stephanie is finished with the steps in the conceptual B. Development of a theoretical basis for nursing indicated. C. “Does the question asked looks as though it is
phase when she has conducted the LAST step, which is C. Increase the accountability of nurses. measuring the appropriate construct?”
A. formulating and delimiting the problem. D. Improves the image of nursing 48. She opts to use interviews in data collection. In D. “Does the instrument correlate highly with an
B. review of related literature addition to validity, what is the other MOST serious external criterion?
C. develop a theoretical framework Answer: (A) Improvement in patient care weakness of this method?
D. formulate a hypothesis The ultimate goal of conducting research is to improve A. Accuracy Answer: (A) “What is this instrument really measuring?”
patient care which is achieved by enhancing the practice B. Sensitivity Construct validity aims to validate what the instrument is
Answer: (D) formulate a hypothesis of nurses when they utilize research results in their C. Objectivity really measuring. The more abstract the concept, the
The last step in the conceptualizing phase of the practice. D. Reliability more difficult to measure the construct.
research process is formulating a hypothesis. The rest
are the first three steps in this phase. 44. Regardless of the significance of the study, the Answer: (A) Accuracy 52. Which of the following experimental research
feasibility of the study needs to be considered. Which of Accuracy and validity are the most serious weaknesses designs would be appropriate for this study if she wants
41. She states the hypothesis of the study. Which of the the following is considered a priority? of the self-report data. This is due to the fact that the to find out a cause and effect relationship between the
following is a null hypothesis? A. Availability of research subjects respondents sometimes do not want to tell the truth for structured discharge plan and compliance to home care
A. Infants who are breastfed have the same weight as B. Budgetary allocation fear of being rejected or in order to please the regimen among the subjects?
those who are bottle fed. C. Time frame interviewer. A. True experiment
B. Bottle-fed infants have lower weight than breast-fed D. Experience of the researcher B. Quasi experiment
infants 49. She plans to subject her instrument to pretesting. C. Post-test only design
C. Cuddled infants sleep longer than those who are left Answer: (A) Availability of research subjects Which of the following is NOT achieved in doing D. Solomon four-group
by themselves to sleep. Availability is the most important criteria to be pretesting?
D. Children of absentee parents are more prone to considered by the researcher in determining whether A. Determines how much time it takes to administer the Answer: (C) Post-test only design
experience depression than those who live with both the study is feasible or not. No matter how significant instrument package Post- Test only design is appropriate because it is
parents. the study may be if there are no available B. Identify parts that are difficult to read or understand impossible to measure the compliance to home care
subjects/respondents, the study can not push through. C. Determine the budgetary allocation for the study regimen variable prior to the discharge of the patient
Answer: (A) Infants who are breastfed have the same D. Determine if the measures yield data with sufficient from the hospital.
weight as those who are bottle fed. 46. Aretha knows that a good research problem exhibits variability
Null hypothesis predicts that there is no change, no the following characteristics; which one is NOT included?
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53. One hypothesis that she formulated is “Compliance people refuse to be interviewed in person. variables in the present which is linked to a variable that
to home care regimen is greater among patients who Answer: (A) Test the cause and effect relationship occurred in the past?
received the structured discharge plan than those who 57. Alyssa reads about exploratory research. Which of among the variable under a controlled situation A. Prospective design
received verbal discharge instructions.’ Which is the the following is the purpose of doing this type of Experimental research is a Level III investigation which B. Retrospective design
independent variable in this study? research? determines the cause and effect relationship between C. Cross sectional study
A. Structured discharge plan A. Inductively develops a theory based on observations variables. D. Longitudinal study
B. Compliance to home care regimen about processes involving selected people
C. Post-open heart surgery patients B. Makes new knowledge useful and practical. 61. She knows that there are three elements of Answer: (B) Retrospective design
D. Greater compliance C. Identifies the variables in the study experimental research. Which is NOT included? Retrospective studies are done in order to establish a
D. Finds out the cause and effect relationship between A. Manipulation correlation between present variables and the
Answer: (A) Structured discharge plan variables B. Randomization antecedent factors that have caused it.
Structured discharge plan is the intervention or the C. Control
‘cause’ in the study that results to an ‘effect’, which is Answer: (C) Identifies the variables in the study D. Trial 65. Situation : Harry a new research staff of the Research
compliance to home care regimen or the dependent Exploratory research is the first level of investigation and and Development Department of a tertiary hospital is
variable. it deals with identifying the variables in the study. Answer: (D) Trial tasked to conduct a research study about the increased
Trial is not an element of experimental research. incidence of nosocomial infection in the hospital.
54. Situation : Alyssa plans to conduct a study about 58. She reviews qualitative design of research. Which of Manipulation of variables, randomization and control are
nursing practice in the country. She decides to refresh the following is true about ethnographic study? the three elements of this type of research Which of the following ethical issues should he consider
her knowledge about the different types of research in A. Develops theories that increase the knowledge about in the conduct of his study?
order to choose the most appropriate design for her a certain phenomenon. 62. Alyssa knows that there are times when only
study. B. Focuses on the meanings of life experiences of people manipulation of study variables is possible and the 1. Confidentiality of information given to him by the
C. Deals with patterns and experiences of a defined elements of control or randomization are not attendant. subjects
55. She came across surveys, like the Social Weather cultural group in a holistic fashion Which type of research is referred to this? 2. Self-determination which includes the right to
Station and Pulse Asia Survey. Which of the following is D. In-depth investigation of a single entity A. Field study withdraw from the study group
the purpose of this kind of research? B. Quasi-experiment 3. Privacy or the right not to be exposed publicly
A. Obtains information regarding the prevalence, Answer: (C) Deals with patterns and experiences of a C. Solomon-Four group design 4. Full disclosure about the study to be conducted
distribution and interrelationships of variables within a defined cultural group in a holistic fashion D. Post-test only design A. 1, 2, 3
population at a particular time Ethnographic research deals with the cultural patterns B. 1, 3, 4
B. Get an accurate and complete data about a and beliefs of certain culture groups. Answer: (B) Quasi-experiment C. 2, 3, 4
phenomenon. Quasi-experiment is done when randomization and D. 1, 2, 3, 4
C. Develop a tool for data gathering. 59. She knows that the purpose of doing ethnographic control of the variables are not possible.
D. Formulate a framework for the study study is to: Answer: (D) 1, 2, 3, 4
A. Understand the worldview of a cultural group 63. One of the related studies that she reads is a This includes all the options as these are the four basic
Answer: (A) Obtains information regarding the B. Study the life experiences of people phenomenological research. Which of the following rights of subjects for research.
prevalence, distribution and interrelationships of C. Determine the relationship between variables questions is answered by this type of qualitative
variables within a population at a particular time D. Investigate intensively a single entity research? 66. Which of the following is the best tool for data
Surveys are done to gather information on people’s A. ” What is the way of life of this cultural group?” gathering?
actions, knowledge, intentions, opinions and attitudes. Answer: (A) Understand the worldview of a cultural B. “What is the effect of the intervention to the A. Interview schedule
group dependent variable?” B. Questionnaire
56. She will likely use self-report method. Which of the The aim of ethnographers is to learn from the members C. “What the essence of the phenomenon is as C. Use of laboratory data.
following self-report methods is the most respected of a cultural group by understanding their way of life as experienced by these people?” D. Observation
method used in surveys? they perceive and live it. D. “What is the core category that is central in explaining
A. Personal interviews what is going on in that social scene?” Answer: (C) Use of laboratory data.
B. Questionnaires 60. Alyssa wants to learn more about experimental Incidence of nosocomial infection is best collected
C. Telephone interviews design. Which is the purpose of this research? Answer: (C) “What the essence of the phenomenon is as through the use of biophysiologic measures, particularly
D. Rating Scale A. Test the cause and effect relationship among the experienced by these people?” in vitro measurements, hence laboratory data is
variable under a controlled situation Phenomenological research deals with the meaning of essential.
Answer: (A) Personal interviews B. Identify the variables in the study experiences as those who experienced the phenomenon
Personal interviews is the best method of collecting C. Predicts the future based on current intervention understand it. 67. During data collection, Harry encounters a patient
survey data because the quality of information they yield D. Describe the characteristics, opinions, attitudes or who refuses to talk to him. Which of the following is a
is higher than other methods and because relatively few behaviors of certain population about a current issue or 64. Other studies are categorized according to the time limitation of the study?
event frame. Which of the following refers to a study of A. Patient’s refusal to fully divulge information.
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B. Patients with history of fever and cough A. MEDLINE NURSING RESEARCH Part 2 Situation 2: Survey and statistics are important part if
C. Patients admitted or who seeks consultation at the ER B. National Institute of Nursing Research research that is necessary to explain the characteristics
and doctors offices C. American Journal of Nursing Situation 1: You are fortunate to be chosen as part of of the population.
D. Contacts of patients with history of fever and cough D. International Council of Nurses the research team in the hospital. A review of the
following IMPORTANT nursing concepts was made: 6. According to WHO statistics on the homeless
Answer: (A) Patient’s refusal to fully divulge information. Answer: (B) National Institute of Nursing Research population around the world, which of the following
Patient’s refusal to divulge information is a limitation National Institute for Nursing Research is a useful source 1. A professional nurse can do research for varied groups of people in the world disproportionately
because it is beyond the control of Harry. of information for nursing research. The rest of the reasons except: represents the homeless population?
options may be helpful but NINR is the most useful site
68. What type of research is appropriate for this study? for nurses. a. Professional advancement through research a. Hispanics
A. Descriptive- correlational participation b. Asians
B. Experiment 72. He develops methods for data gathering. Which of b. To validate results of new nursing modalities c. African Americans
C. Quasi-experiment the following criteria of a good instrument refers to the c. For financial gains d. Caucasians
D. Historical ability of the instrument to yield the same results upon d. To improve nursing care
its repeated administration? 7. All but one of the following in not a measure of
Answer: (A) Descriptive- correlational A. Validity 2. Each nurse participant was asked to identify a central tendency:
Descriptive- correlational study is the most appropriate B. Specificity problem. After the identification of the research
for this study because it studies the variables that could C. Sensitivity problem, which of the following should be done? a. Mode
be the antecedents of the increased incidence of D. Reliability b. Variance
nosocomial infection. a. Methodology c. Standard deviation
Answer: (D) Reliability b. Review of related literature d. Range
69. In the statement, “Frequent hand washing of health Reliability is consistency of the research instrument. It c. Acknowledgement
workers decreases the incidence of nosocomial refers to the repeatability of the instrument in extracting d. Formulate hypothesis 8. In the values: 87, 85, 88, 92, 90, what is the mean?
infections among post-surgery patients”, the dependent the same responses upon its repeated administration.
variable is 3. Which of the following communicate the results of a. 88.2
A. incidence of nosocomial infections 73. Harry is aware of the importance of controlling the research to the readers. They facilitate the b. 88.4
B. decreases threats to internal validity for experimental research, description of the data. c. 87
C. frequent hand washing which include the following examples EXCEPT: d. 90
D. post-surgery patients A. History a. Hypothesis
B. Maturation b. Statistics 9. In the values: 80, 80, 80, 82, 82, 90, 90, 100, what is
Answer: (A) incidence of nosocomial infections C. Attrition c. Research problem the mode?
The dependent variable is the incidence of nosocomial D. Design d. Tables and graphs
infection, which is the outcome or effect of the a. 80
independent variable, frequent hand washing. Answer: (D) Design 4. In quantitative data, which of the following is b. 82
Design is not a threat to internal validity of the described as the distance in the scoring units of the c. 90
70. Harry knows that he has to protect the rights of instrument just like the other options. variable from the highest to the lower? d. 85.5
human research subjects. Which of the following actions
of Harry ensures anonymity? 74. His colleague asks about the external validity of the a. Frequency 10. In the values: 80, 80, 10, 10, 25, 65, 100, 200, what is
A. Keep the identities of the subject secret research findings. Which of the responses of Harry is b. Mean the median?
B. Obtain informed consent appropriate? The research findings can be c. Median
C. Provide equal treatment to all the subjects of the A. generalized to other settings or samples d. Range a. 71.25
study. B. shown to result only from the effect of the b. 22.5
D. Release findings only to the participants of the study independent variable 5. This expresses the variability of the data in reference c. 10 and 25
C. reflected as results of extraneous variables to the mean. It provides as with a numerical d. 72.5
Answer: (A) Keep the identities of the subject secret D. free of selection biases estimate of how far, on the average the separate
Keeping the identities of the research subject secret will observation are from the mean: 11. Draw lots, lottery, table of random numbers or a
ensure anonymity because this will hinder providing link Answer: (A) generalized to other settings or samples sampling that ensures that each element of the
between the information given to whoever is its source. External validity refers to the generalizability of research a. Mode population has an equal and independent chance of
findings to other settings or samples. This is an issue of b. Standard deviation being chosen is called:
71. He is oriented to the use of electronic databases for importance to evidence-based nursing practice. c. Median
nursing research. Which of the following will she likely d. Frequency a. Cluster
access? b. Simple
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c. Stratified updated on the latest trends and issues affecting the a. Consent to incomplete disclosure d. A study measuring differences in blood pressure
d. Systematic profession and the best practices arrived at by the b. Description of benefits, risks, and discomforts before, during and after a procedure
profession. c. Explanation of procedure
12. An investigator wants to determine some of the d. Assurance of anonymity and confidentiality 24. An 85 year old client in a nursing home tells a nurse,
problems experienced by diabetic clients when using 16. You are interested to study the effects of mediation “I signed the papers for that research study because
insulin pump. The investigator went to a clinic where and relaxation on the pain experienced by cancer 20. In the hypothesis: “The utilization of technology in the doctor was so insistent and I want him to
he personally knows several diabetic clients having patients. What type of variable is pain? teaching improves the retention and attention of the continue taking care of me”. Which client right is
problem with insulin pump. The type of sampling nursing students,” which is the dependent variable? being violated?
done by the investigator is called: a. Dependent
b. Correlational a. Utilization of technology a. Right of self determination
a. Probability c. Independent b. Improvement in the retention and attention b. Right to privacy and confidentiality
b. Purposive d. Demographic c. Nursing students c. Right to full disclosure
c. Snowball d. Teaching d. Right not to be harmed
d. Incidental 17. You would like to compare the support system of
patient with chronic illness and those with acute Situation 4: You are an actively practicing nurse who has 25. “A supposition or system of ideas that is proposed to
13. If the researcher implemented a new structured illness. How will you best state your problem? just finished your graduate studies. You learned the explain a given phenomenon”, best defines:
counseling program with a randomized group of value of research and would like to utilize the knowledge
subject and a routine counseling program with a. A descriptive study to compare the support and skills gained in the application of research to the a. A paradigm
another randomized group of subject, the research is systems of patients with chronic illness and nursing service. The following questions apply to b. A concept
utilizing which design? those with acute illness in terms of demographic research. c. A theory
data and knowledge about intervention d. A conceptual framework
a. Quasi experimental b. The effects of the types of support system of 21. Which type of research inquiry investigates the
b. Experimental patients with chronic illness and those with issues of human complexity (e.g. understanding the Situation 5: Mastery of research design determination is
c. Comparative acute illness human expertise)? essential in passing the NLE.
d. Methodological c. A comparative analysis of the support system of
patients with chronic illness and those with a. Logical position 26. Monette wants to know if the length of time she will
14. Which of the following is not true about a pure acute illness b. Naturalistic inquiry study for the board examination is proportional to
experimental research? d. A study to compare the support system of c. Positivism her board rating. During the December 2007 board
patients with chronic illness and those with d. Quantitative Research examination, she studied for six months and gained
a. There is a control group acute illness 68%. On June 2008 board exam, she studied for 6
b. There is an experimental group e. What are the differences of the support system 22. Which of the following studies is based on months again for a total of one year and gained 74%.
c. Selection of subjects in the control group is being received by patient with chronic illness quantitative research? On November 2008, she studied for 6 months for a
randomized and patients with acute illness? total of one and a half year and gained 82%. The
d. There is a careful selection of subjects in the a. A study examining the bereavement process in research design she used is:
experimental group 18. You would like to compare the support system of spouses of clients with terminal cancer
patients with chronic illness to those with acute b. A study exploring factors influencing weight a. Comparative
15. The researcher implemented a medication regimen illness. Considering that the hypothesis was: “Clients control behavior. b. Correlational
using a new type of combination drugs to manic with chronic illness have lesser support system than c. A study measuring the effects of sleep c. Experimental
patients while another group of manic patients clients with acute illness.” What type of research is deprivation on wound healing d. Qualitative
receives the routine drugs. The researcher however this? d. A study examining client’s feeling before, during
handpicked the experimental group for they are the and after a bone marrow aspiration 27. Rodrigo was always eating high fat diet. You want to
clients with multiple episodes if bipolar disorder. The a. Descriptive determine if what will be the effect of high
researcher utilized which research design? b. Correlational, non experimental 23. Which of the following studies is based on cholesterol food to Rodrigo in the next 10 years. You
c. Experimental qualitative research? will use:
a. Quasi experimental d. Quasi experimental
b. Pure experimental a. A study examining clients reactions to stress a. Comparative
c. Phenomenological 19. In any research study where individual persons are after open heart surgery b. Correlational
d. Longitudinal involved, it is important that an informed consent of b. A study measuring nutrition and weight loss/gain c. Historical
the study is obtained. The following are essential in clients with cancer d. Longitudinal
Situation 3: As a nurse, you are expected to participate information about the consent that you should c. A study examining oxygen levels after
in initiating or participating in the conduct of research disclose to the prospective subjects except: endotracheal suctioning 28. Community A was selected randomly as well as
studies to improve nursing practice. You have to be Community B, nurse Crystal conducted teaching to
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Community A and assessed if Community A will have these people. They will best use which research 37. Which of the following usually refers to the BBBBA
a better status than Community B. This is an design? independent variables in doing research?
example of:
a. Historical a. Result
a. Comparative b. Case study b. Cause
b. Correlational c. Phenomenological c. Output
c. Experimental d. Ethnographic d. Effect
d. Qualitative
34. Jezza and Jenny researched about TB – its 38. The recipients of experimental treatment in an
29. Faye researched in the development of a new way to transmission, causative agent and factors, experimental design or the individuals to be
measure intelligence by creating a 100-item treatment, signs and symptoms, as well as observed in a non-experimental design are called:
questionnaire that will assess the cognitive skills of medication and all other in-depth information about
an individual. The design best suited for this study is: tuberculosis. This study is best suited for which a. Setting
research design? b. Subjects
a. Historical c. Treatment
b. Methodological a. Historical d. Sample
c. Survey b. Case study
d. Case study c. Phenomenological 39. The device or techniques that Vinz employs to
d. Ethnographic collect data is called:
30. Jay Emmanuelle is conducting a research study on
how Ralph, an AIDS client lives his life. A design 35. Diana, Arlene, and Sally are to conduct a study about a. Sample
suited for this is: relationship of the number of family members in the b. Instrument
household and the electricity bill, which of the c. Hypothesis
a. Historical following is the best research design suited for this d. Concept
b. Case study study?
c. Phenomenological 40. The use of another person’s ideas or wordings
d. Ethnographic 1. Descriptive without giving appropriate credit results from
2. Exploratory inaccurate or incomplete attribution of materials to
31. Maecee is to perform a study about how nurses 3. Explanatory its resources. Which of the following is referred to
perform surgical asepsis during World War II. A 4. Correlational when another person’s idea is inappropriately
design best for this study is: 5. Comparative credited as one’s own?
6. Experimental
a. Historical a. Plagiarism
b. Case study a. 1 and 4 b. Quotation
c. Phenomenological b. 2 and 5 c. Assumption
d. Ethnographic c. 3 and 6 d. Paraphrase
d. 1 and 5
32. Medel conducts sampling at Barangay Maligaya. He e. 2 and 4
collected 100 random individuals and determine
who is their favorite actor. 50% said Piolo, 20% said Situation 6: As a nurse researcher, Vinz must have a very
John Lloyd, while some answered Sam, Dingdong, good understanding of the common terms of concept
Richard, and Derek. Medel conducted what type of used in research.
research study?
36. The information that an investigator like Vinz
a. Phenomenological collects from the subjects or participants in a Nursing Research Suggested Answer Key
b. Case study research study is usually called:
c. Non experimental CBDDB
d. Survey a. Hypothesis BABAD
b. Data BBBDA
33. Mark and Toberts visited a tribe located somewhere c. Variable AEAAB
in China, it is called Shin Jea tribe. They studied the d. Concept BCAAC
way of life, tradition, and the societal structure of BDCBC
ADDBD
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Nursing Board Practice Test Compilation

5. Benner’s “Proficient” nurse level is different

a. grievance d. It should disclose previous diagnosis, d. Iron 75 mg/100 ml

gain independence as quickly as possible. Which include: b. Medicine preparation is correct

B. Five years B. have increased hepatic, renal and D. Chronic poverty

closely watched? c. 50 days

Situation: Basic knowledge on Intravenous solutions is order?

a. Colace (Docusate) to: d. Cleaning d. Tetany

expansion of the plant, major c. The Chinese Triad

B. general anesthesia A. Emotional crisis B. Self-esteem disturbance

d. Sulfamylon ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC 51. C

persecution hospital stimulated her anger by using a condescending tone of

persecution hospital stimulated her anger by using a condescending tone of

b. Administering Coumadin c. Lower cost with reusable insulin

accordance with the correct outline plan for A. 651

in the Philippines are 4. Death from CVD : 3,029 A. 1/100

diagnostic examination? C. Population pyramid

PSYCHIATRIC NURSING Part 1 b. Avoiding relationship a. Cardiac dysrhythmias resulting to c. Shame

50. C. Alcohol is a central nervous system PSYCHIATRIC NURSING Part 3 a. Projection

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