NP 1 knowledge base.

This is comparable to
the ______that physicians use as their
1. It is a stimulus, either external or knowledge.
internal, that produces tension and results A. Psychological system
in a degree of instability. B. Interpersonal system
A. Equilibrium C. Dependency subsystem
B. Stressor D. Biological system
C. Subsystem
D. Homeostasis 7. It promotes helping behavior that calls
for a nurturing response. Its
2. Which subsystem has the dual consequences are approval, attention,
functions of procreation and gratification? or recognition, and physical assistance.
A Aggressive This refers to:
B. Dependency A. Attachment subsystem
C. Achievement B. Aggressive subsystem
D. Sexual C. Dependency subsystem
D. D. Ingestive and Eliminative
3. Who was the early proponent of subsystem
nursing as a science as well as an art?
A. Sister Callista Roy 8. The conservation model of Myra Levine
B. Dorothy Johnson shows that family solidarity is a way of:
C. Imogene King A. Conservation of personal integrity
D. D. Myra Levine B. Conservation of structural integrity
C. Conservation of energy
4. Who proposed that the science of D. Conservation of social integrity
nursing necessary for effective nursing
care included a synthesis of key concepts 9. Eddie enhances his self-esteem through
drawn from basic and applied sciences? good personal hygiene. He wants to
A. Sister Callista Roy conserve his:
B. Dorothy Johnson A. Personal Integrity
C. Imogene King B. Social integrity
D. Myra Levine C. Structural Integrity
D. Energy
5. The of nursing should focus on the
patient as an individual and not on the 10. She proposed the use of 4 conservation
specific disease entity: principles to guide nursing practice:
A Standards & practices A. Martha Rogers
B. Philosophy* B. Myra Lavine
C. Process & therapy C. Margaret Newman
D. Science & art D. Myra Levine

6. Johnson stated that a nurse should use 11. The Conservation Model is focused on
the behavioral system as their the
 A. Prevention of the spread of disease 17. When the nurse is setting goals for
B. Promotion of individual’s wholeness the patient, what step of the nursing
C. Prevention of the spread of disease process is she already at?
D. D. All of the above A. Assessment
B. Implementation
12. Based on the ADAPTATION MODEL, C. Evaluation
the person is a/an: D. Planning
A. Biopsychosocial adaptive system
B. Biological-adaptive system 18. All but one is the classification of
C. Adaptive system STIMULI:
D. Maladaptive system A. Focal
B. Contextual
13. The following are the feedback C. Conceptual
cycles, EXCEPT? D. Residual
A. Input
B. Output 19. Which stimulus has the most
C. Throughput immediate effect on a person? A Focal
D. Parietal B. Contextual
C. Conceptual
14. Which feedback cycle pertains to the D. Residual
control processes?
A. Input 20. Environment refers to the internal
B. Output and external environments of the person.
C. Throughput Internal environment is composed of the
D. All of the above physiologic and pathophysiologic domains
of the person. External environment has
15. In the ADAPTIVE MODES three levels: perceptual, operational, and
presented by Roy, which one reflects social conceptual. Lance knows that this level
integrity and other role-related concepts? refers to things that physically affect the
A. Physiologic-Physical individual but may not be perceived by the
B. Self-concept Group identity individual himself:
C. Role Function A. Perceptual level
D Interdependence B. Operational level
C. Conceptual level
16. Which phase/step of the nursing D. Any of the above
process is involved when the nurse gathers
data about the patient's condition? 21. It is a body defense mechanism
A. Assessment that protects the body tissue from insults
B.Diagnosis in an unfriendly environment: A. Fight or
C. Planning flight*??
D. Evaluation B. Response to stress
C. Inflammatory response
D. Perceptual awareness
 22. It refers to the wear and tear of body
tissues that reflect the body's continued
response and adaptation to stressful
situations. It is characterized by
irreversibility. It influences the way the
patients respond to nursing care
A. Fight or flight
B.Response to stress
C.Inflammatory response
DPerceptual awareness
23. The primary purpose of nursing is:
A. Health promotion
B. Disease prevention
C. Rehabilitation
D. Treatment
24. Are statements of clinical judgments
about the individual, family or community
response to actual or potential health
problems and life processes that reflect
patient behaviors patient status and provide
the basis for selection of nursing
interventions to achieve desired outcomes:
A. Nursing process
B. Nursing diagnosis
C. Nursing analysis
D. Nursing planning
25. It refers to the actualization of both
innate and obtained human potential
gleaned from rewarding relationships with
others, goal directed behavior, and expert
personal care
A. Nursing care
B. Optimum health
C. Wellness
D. Optimum care
26. Who postulated the WHOLISTIC
concept that the totality is greater than the
sum of its parts? A. Sister Callista Roy
B. Virginia Henderson
C. Martha Rogers
D. Joyce Travelbee
27. Martha Roger's theory asserts that
nurses should focus on:
A. Patient's needs
B. Decreasing the stressors
C. Totality of the person
D.Prevention of Diseases
28. Rogers viewed the person as an
open system in constant process with the
open system of the environment. She
added that man is describe by the following
statements, except:
A. Not unified whole possessing his own
integrity and manifesting characteristics
thought, sensation, and emotion, B. In
continuously exchanging matter and energy
with the environment
C.Identified by pattern and organization and
reflects his innovative wholeness D.
Characterized by the capacity for
abstraction and imagery, language and
thought, sensation, and emotion.
29. It refers to the state in which the human
being is regarded as a unified whole which
is more than and different from the sum"öf
the parts:
A Wholeness
B.Openness
C.Open systems
D. Undirectionality
30. Are the fundamental unit of the
living and the non-living? A Energy
fields
B. Environmental field
C Pan dimensionality
D. Wholeness
31. The person according to Neuman's
theory has 3 lines of defenses, which
among the following lines below serves as a
guide to assess deviations from the client's
usual wellness?
A. Flexible line of defense
B. Lines of Resistance
C. Normal line of defense
D. Normal lines of resistance
32. While the line that serves as a
protective layer for preventing stressors
from breaking through the usual wellness
state is?
A. Flexible line of defense
B. Lines of Resistance
C. Normal line of defense
D. Normal lines of resistance
33. In the SYSTEMS MODEL, there are
3 modalities of prevention. What type of
prevention is carried out when the client is
already manifesting the signs and
symptoms from stress? A Primary
Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Any of the above
34. What type of prevention is
appropriate before symptoms occur? A
Primary Prevention
B.Secondary Prevention
C.Tertiary Prevention
D. Any of the above
35. What is the focus of nursing in Primary
Prevention?
A Return of system client balance or client
wellness.
B. Strengthen the flexible line of defense
C. Build up the internal lines of resistance.
D. All of the above
36. On the other hand, this type of
prevention focuses on the return of system
client balance, or client wellness:
A Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Any of the above
37. The Systems Model of Betty Neuman
identified stressors as capable of producing
either a positive or negative effect on the
system. She described them as
interpersonal , meaning
A. Occurring within the person
B. Occurring outside the individual
C. Occurring outside the individual
D. Occurring within the environment
38. Natural calamities like flood &
landslides are examples of: A
Intrapersonal stressors
B. Interpersonal stressors
C. Extra- personal stressors
D. Both A and C
39. To maintain & retain systems
stability, the nurse can do which of the
following?
A. Educate the patient how to prevent
dengue infestation
B. Administer the medication as
ordered by the doctor
C. Administer immunization to the
children
D. All of the above
40. Arrange the following steps in
nursing process
I. Diagnosis
II. Planning
III. Evaluation
 IV. Implementation 44. Which of the following is considered
V. Ässessment as rules of performance in a redesigned
Health Care System?
A. V, i, i, iii and iv A. Safety is a system property &
B. V, i, iii, i and ii focused on increasing errors
C. V, iii, ii, iv, i B. Waste is continuously decreased
D. V, i, ii, iv and iii C. Transparency is necessary through
41. An area of nursing that involves withholding information to patients &
comforting and caring for people of all ages families.
who are dying? D. Cooperation & communication
among clinicians are not priorities
A. Promoting Health and Wellness but needed
B. Preventing illness
C. Palliative care 45. This is an organization that analyzes
D. Providing medications and evaluates current performance and
uses the results to develop focused
42. A nurse has instituted a turn improvement actions:
schedule for a patient to prevent skin
breakdown. Upon evaluation, the nurse A. Quality Improvement
finds that the patient has a stage II B. Performance Improvement
pressure ulcer on the buttocks. Which C. Quality Improvement Data
action will the nurse take next? D. Quality Data

A. Reassess the patient and situation 46. What is the meaning of the PDSA
B. Revise the turning schedule to Cycle?
increase the frequency. A. Plan, Do, Study, Assess
C. Delegate turning to the nursing B. Plan, Do, Study, Access
assistive personnel. C. Plan, Do, Study, Act
D. Apply medication to the area of skin D. Plan, Do, Study, Alter
that is broken down.
47. In providing holistic care to Tin, the
43. The nurse inserts an intravenous nurse should consider all dimensions of the
(IV) catheter using the correct technique patient's health - physically, emotionally,
and following the recommended steps psychologically. socially, and spiritually.
according to standards of care and hospital This best exemplifies what nursing role?
policy. Which type of implementation skill is A. Case Manager
the nurse using? B. Client Advocate
C. Change Agent
A. Cognitive D. Caregiver
B. Interpersonal
C. Psychomotor 48. Part of the providing services and
D. Judgmental care, Nurse Sam must speak to Clee to
relay information and/or to assess verbal
and non-verbal cues from the patient to
determine any client concerns. By so doing,
the nurse assumes what role?
A. Communicator
B. Leader
C. Teacher
D. Counselor
49. Patient Ying is admitted in the
psychiatric unit of Metro Iloilo Medical
Center, due to alcohol addiction. Nurse
Sam, assist him in his therapy while
coordinating his plan of care to other health
care team. Through this, he can modify his
behavior. This exemplifies what role of the
nurse?
A. Nurse Leader
B. Counselor
C. Client Advocate
D. Nurse Manager
50. In advanced practice nursing, which
of the following statements reflects a role of
Clinical Nurse Specialist?
A. Provides care and services under
the supervision of an
anesthesiologist.
B. Provides independent care,
including pregnancy and
gynecological services
C. Expert clinician in a specialized
area of practice such as adult
diabetic care.
D. Provides comprehensive care,
usually in a primary care setting,
directly managing the medical care
of patients who are healthy or have
chronic conditions.
51. Nurse Hiromi is presenting
information to a management class of
nursing student regarding financial
reimbursement for achievement of
measurable patient outcomes. As a student
nurse, you know that this is on which topic?
A. Prospective Payment System
B. Managed Care System
C.Capitation Payment System
D. Pay for Performance
52. Nurse Aya is providing restorative
care to a patient following an extended
hospitalization for influenza. Which of the
following is an appropriate goal for
restorative care?
A. The patient will be able to heal
without signs of infection.
B. The patient will express concerns
related to going home.
C. The patient will identify strategies to
boost the immune system.
D. The patient will be able to walk 100
feet without breath shortness.
53. Which of the following nursing
activities is provided in a secondary health
environment?
A. Performing suctioning for a patient
on a mechanical ventilator.
B. Performing the first wound dressing
for a patient in the unit after surgery.
C. Conducting blood pressure
screening for pregnant women at the
Health Center.
D. Teaching a patient diagnosed with
asthma on how to perform deep
breathing exercises
54. While doing your requirements as a
student nurse in the nurse's station, the staff
nurse on your duty suddenly had to leave
the station immediately as one of her
patients was having code. You observed
that the computer monitor displayed a
medical history of a patient not assigned to
your care. What would be your most
appropriate action?
A. Call the attention of your clinical
instructor and report the incidence.
 B. Print the documents to serve as a
future reference, if in case the
patient will be assigned to your care.
C. Turn off the computer as soon as
possible
D. Read the medical history for
educational purposes.
55. What does HIPAA mandates to all
health care personnel with regards to
patient's records? A. Privacy
B. Availability
C. Accessibility
D. Confidentiality
56. Trisha, an irate patient admitted last
week, informs the clerk, "This is too much! I
have paid a ton of money every time I come
to this hospital, even the clinics for routine
check-ups. Those medical records belong
to me. I need them now!" What would be
the best response to Trisha?
A. "Your original health care record
belongs to the hospital. However, I
may only give you the duplicate
copies.'
B. "I am required to give you a request
form. This is intended to prove that
you personally need your medical
records, and not just anyone else."
C. "One moment please. Let me get
them for you. Just relax and calm
yourself."
D. "I am so sorry, but you do not have
the right to look at your own medical
records.'
57. Critical pathways are
interprofessional care plans that identify
patient problems, key interventions, and
expected outcomes within an established
time frame. As a student nurse, you know
that these pathways are, except:
A. These allow the staff nurses to
develop standardized integrated care plans
for projected length of stay for patients of a
specific case type.-
B. The exact contents and format of
these must be the same among different
institutions to be standardized.
C. These delve in cases occur in high
volumes and are predictable
D. These replace other nursing forms,
such as the nursing care plans.- E.charting
by exception is usually the method used.
58. Nurse Kenji had been assigned to
patient Luke who had been admitted to the
hospital with chief complaints of gastric
upset and fever. The physician ordered
HNBB 20mg/mL IV q4h. Due to
incompetence, Nurse Kenji missed to verify
the doctor's order and administered HNBB
per Orem. He immediately reported this to
his nursing supervisor and required him to
put this in documentation. Which of the
following should not be considered when
writing an incident report?
A. Assessment and judgment of the
incident from your point of view.
B. Do not admit liability or give
unnecessary details.
C. When writing the incident to the
patient's chart, do not mention the incident
report. D. List the date, time, and care
given to patient and the name of the doctor
to be notified.
59. Sashi, a new graduate nurse, is
employed in a public hospital utilizing the
Focus Charting in nurse's notes. Which of
the following statements regarding this
format of documentation is/are correct: I.
Some agencies include patient teachings-
II. Data, action, response, patient teachings-
 Ill. Response is the same as evaluation.-
IV. Action combines planning and
implementation.-
V. Must use all the steps each time you
make
nurse's notes on particular focus.
VI. Data is both subjective and objective
A. I, I, IV. V. VI
B. II, III, IV. V, VI
C. I. II. III. V. VI — FEEL NAKO KANI.
E CHECK LNG PLS. SA FDAR NI
D. I. II. Ill IV. VI
60. Which of the following is considered
as a Passive Strategy of health
promotion? A Smoking Cessation
Program
B. Fluoridation of Municipal Drinking
Water
C. Fitness Activity (Zumba Dance) every
5:00 PM
D. Weight Reduction Program
61. Nurse Jacob is presenting to the
senior high school student covering the
facts about HIV awareness in a certain
public school.
Which level of prevention is he practicing?
A. Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Quaternary Prevention
62. A charge nurse is reviewing
outcome statements using the SMART
approach. Which patient outcome
statement will the charge nurse praise to
the new nurse? A. The patient will
ambulate in hallways.
B. The nurse will monitor the patient's
heart rhythm continuously this shift.
C. The patient will feed self at all
mealtimes today without reports of
shortness of breath.
D. The nurse will administer pain
medication every 4 hours to keep the
patient free from discomfort.
63. A patient's son decides to stay at the
bedside while his father is confused. When
developing the plan of care for this patient,
what should the nurse do?
A Individualize the care plan only according
to the patient's needs
B. Request that the son leave at
bedtime, so the patient can rest.
C. Suggest that a female member of
the family stay with the patient.
D. Involve the son in the plan of care as
much as possible
64. Risk factors play a major role in how a
nurse identifies a patient's health status.
Which of the following is not considered as
a risk factor? A. Genetic predisposition
B. Age
C. Poor diet
D Low education attainment
65. In caring for a client with chronic
disease, Nurse Star is performing skillfully
the needed nursing interventions to alleviate
the client's pain while preserving his dignity.
According to Swanson's Theory of Caring,
this is included in what caring process?
A. Knowing
B. Being With
C. Doing For
D. Enabling
E. Maintaining Belief
66. Of the five caring processes described
by Swanson, which describes "Being With"?
A. Providing for another as he would do for
themselves
B. Being emotionally there for another
person
C. Striving to understand an event as
meaning for another person
D. Sustaining faith in one's capacity to
get through a situation
67. A student nurse wants to clarify touch
from a caring perspective. As a nurse, what
will be your best response?
A. "I do not touch the patient unless I am
performing a procedure or doing an
assessment.
B "Touch is only used when a patient is in
pain."
C."Touch is a type of verbal communication
D. "Touch forms a connection between the
nurse and patient.
68. Nurse Edward enters patient Bella's
room arranges the supplies for endotracheal
suctioning, and explains the procedure to
her He informs the patient what to expect
during the procedure. Nurse Edward
proceeds to skillfully perform endotracheal
suctioning. This is an example of what type
of touch.
A.Protective Touch
B Task-Oriented Touch
C. Interpersonal Touch
D. Caring Touch
69. Which of the following is not an
outcome of nurses providing presence to
patients?
A. Alleviating suffering
B. Personal growth
C. Connectedness
D. Decreasing sense of isolation and
vulnerability
70. Nurse Rhoda is attending to Patient
Pinas. She is not only physically present,
but also understands the patient's
concerns and health issues. She is
manifesting: A. Being there to the patient.
B. Being with the patient.
C. Being for the patient.
D. Being together with patient.
71. This is a form of nonverbal
communication which influences a patient's
security and comfort, enhances self-esteem,
increases confidence of health team &
improves well-being.
A. Contact Touch
B. Noncontact Touch
C.. Task-Oriented Touch
D. Protective Touch
e. Caring Touch
72. All of the following are guiding principles
for the role of the nurse in the future of
patient care delivery, except?
A. Managing the journey
B. Relationships of virtual care presence a
Knowledge is analyzed
C. The core of nursing is knowledge and
caring
D. None of the above
73. All of the following serve as
guidelines for quality documentation,
except? A Writing in detailed, narrative
format. B. Avoiding the use of jargons or
abbreviations.
C. Sticking to the facts.
D. Use short sentences.
74. Nurse Sky has been assigned as a
reliever today. At 2:00 AM, a patient has
been rushed to the ER department with a
case of Motor Vehicular Accident (MVA).
After gathering the patient's necessary data,
the nurse informed the doctor via telephone
call. The doctor then provided numerous
orders to be done to the patient As a nurse,
which of the following guidelines must be
considered in accepting telephone orders?
A. Read back any prescribed orders made
to the doctor. ???
B. Document every detail of the order into
the physician's order sheet.
C. Follow agency's protocols regarding
telephone orders
D. Sign the complete name of the physician.
75. In the problem-oriented medical record
(POMR), which of the following is
questionable in listing the problem?
A. Team members list the problems in
alphabetical order.
B. Team members add and date new
problems as they arise.
C. The problem list includes a patient's
physiological, psychological, social,
cultural, spiritual, developmental, and
environmental needs.
D. When a problem is resolved, the text
of that problem is lined out
76. The nurse supervisor is assisting a new
nurse on faxing a medical record of her
patient for immediate clinical needs. Which
of the following if done by the nurse must be
interrupted by her nurse supervisor? A. The
nurse uses a cover sheet.
B. The nurse authenticates the data to
verify the source and destination are
correct after transmission.
C. The nurse uses an encryption
feature on the machine.
D. The nurse verifies the fax number of
the transmittal confirmation sheet
77. Which of the following documentation
entries is most accurate?
A. "Patient arrived to ER clutching
chest, restless, and diaphoretic. Reports
midsternal chest pain radiating to left
shoulder starting 30mins ago, pain scale of
8/10. VS of BP: 180/100, HR: 102, RR: 22,
T: 37.5°C and 02Sat of 97%.'
B. "Patient arrived to ER via wheelchair
with chief complaints of chest pain. Upon
assessment, patient is restless and
diaphoretic. VS taken and recorded on
PR sheet's
C. "Patient arrived to ER at 12:03AM
due to chest pain"
D "Patient reported midsternal chest pain
radiating to left shoulder starting 30mins
ago, pain scale of 8/10. Informed the AP
with patient's status and carried out orders
made. VS of BP: 180/100, HR: 102, RR:
22, T: 37.5°C and 02Sat of 97%. Endorsed
to private room for further monitoring.'
78. In developing communication skills,
Nurse Marco recognizes different opinions
that may conflict with his patient. This is
showing what aspect of attitude?
A. Self-Confidence
B. Integrity
C. Humility
D. Critical Thinking
E. Ethical Standards of Care
79. This is an assessment and
communication technique that enables use
of self-awareness, motivation, empathy,
social skills to build therapeutic relationship
with patients? A. Motivational Interview
B. Narrative Approach
C. Emotional Intelligence
D. Perceptual Biases
80. Student Nurse Xia is about to perform
NGTfeeding for the first time with her clinical
instructor's guidance. Before preparing the
equipment needed, she whispers "This is
my opportunity to learn, and I can ask for
help. This is what type of communication?
A. Intrapersonal Communication
B. Interpersonal Communication
C. Small-Group Communication
D. Public Community Communication
E. Electronic Communication
81. All are considered negative
feedback mechanism, except: A. Body
temperature regulation
B.Uterine contractions during delivery
C. Increase in blood pressure
D. Doing exercises.
82. Which of the following activities does
NOT represent an anatomical study:
A. making a section through the heart to
observe its interior
B.examining the surface of a bone
C.viewing muscle tissue through a
microscope
D. studying how the nerves conduct
electrical impulses
e. observing the parts of a reproducing cell
83. Disruption in normal functioning of cells
may result in death. One possible cause of
disruption is the occurrence of disease.
A. The first statement is correct. The
second statement is wrong.
B. The first statement is wrong. The second
statement is correct.
C. Both statements are correct.
D. Both statements are wrong.
84. Carrier mediated transport
mechanisms:
(Select all that apply)
A. Exhibit specificity.
B. Function to move small water-soluble
molecules.
C Function to move electrically charged
ions.
D. Include facilitated diffusion, active
transport, and secondary active transport.
85. Understanding tissue structure and
function is important because A. There
is a relationship between the structure
of each tissue type (how it is organized)
and its function (what it does) B. There
is a relationship between tissue
structure and organ function.
C. Many diseases and pathologies are
tissue and cell type specific.
D.Changes at the tissue level affect the
function of organs
E. All of these are correct.
F. All are correct except option C.
86. Which of these is NOT one of the
four basic tissue types? A. glandular
B. connective
C. muscle
D. epithelium
E. nervous
87. Basement membranes:
A. Function as a filter and barrier to cell
or pathogen movement
B. Attach epithelial cells to the
underlying tissue
C. Are secreted partially by epithelial
cells and partially by the cells of the
underlying tissue.
D. Function as a filter and barrier to cell
or pathogen movement, attach epithelial
cells to the underlying tissue and are
secreted partially by epithelial cells and
partially by the cells of the underlying tissue
are true of basement membranes. E. None
of these is correct.
88. All are true statement about
epithelial tissue: (Select all that apply) A
Epithelial tissue is vascular B. Epithelial
tissue provides physical protection for
organs.
C. Epithelial tissue functions in
absorption & secretion.
D. Epithelial tissue controls the
permeability into and out of an area/organ.
E. Epithelial tissue consists almost
entirely of extracellular material between
them thereby forming a barrier against
entry into the body.
89. Which of these is not a factor that
control stroke volume?
A. sympathetic stimulation of the
myocardium
B. end-diastolic volume
C. end-systolic volume
D. cardiac output
E. contractility of the heart
90. A client with pyrexia will most likely
demonstrate:
A. Elevated blood pressure
B. Dyspnea
C. Increased pulse rate
D. Precordial pain
91. The Nurse explains to a client that
the mechanism mediating long-term
blood pressure regulation is the A.
Adjustment of urinary output
B. Fight or flight response
C. Capillary fluid shifts
D. Nervous system baroreceptors
92. The nurse is assisting a client to the
bedside commode to urinate. Which brain
structures influence the client's bladder
function? Select all that apply.
A. Brainstem,
B. Hypothalamus.
C. Thalamus.
D. Cerebral cortex.
93. Compression of what nerve arising from
the brachial plexus results in numbness,
tingling, and pain in the fingers, a condition
called carpal tunnel syndrome. A. Median
nerve
B. Musculocutaneous nerve
C. Axillary nerve
D.Radial nerve
94. When a variation outside of normal
limits triggers an automatic response that
corrects the situation, the mechanism is
called:
A Homeostasis
B. positive feedback
C. Crisis management
D Negative feedback
95. The sciatic nerves arise from which
of these plexuses? A. Cervical
B. Choroid
C. Lumbosacral
D. Brachial
96. Which part of the neuron
receives information? A. The axon
B. The dendrite
C. The Node of Ranvier
D. The myelin sheaths
97. A role of immunoglobulin G (IgG) is to:
A. Activate the T-cell lymphocytes
B. Activate the kinin system
C. Activate the complement system
D. Activate the process of inflammation -
MAO NI di man ma edit sa phonw
hahahaha
98. Which of the following is an example of
naturally acquired active immunity?
A. A child receives the measles,
mumps, and rubella (MMR) vaccine.
B. An adult contract a streptococcus
infection and recovers in a couple of weeks.
C. A child bitten by a rabid animal receives
an injection of rabies antibodies.
D. Antibodies pass from mother to
the developing child in the womb. E.
All of the above.
99. The endocrine functions of the kidney
and the heart include the production and
secretion of the hormones:
A. insulin and glucagon
B. erythropoietin and atrial natriuretic peptic
C. epinephrine and norepinephrine
D. renin and angiotensinogen

100. Which of the following does not

stimulate the release of renin from the
kidneys?
A. a decline in renal blood flow
B. parasympathetic stimulation
C. sympathetic stimulation
D. none of the above
NP 2
1. Which is the primary goal of community
health nursing?
A. To support and supplement the
efforts of the medical profession in the
promotion of health and prevention of
illness
B. To enhance the capacity of
individuals families and communities to
cope with their health needs
C. To increase the productivity of the
people by providing them with services that
will increase their level of health
D. To contribute to national
development through promotion of family
welfare, focusing particularly on mothers
and children.
2. CHN is a community-based practice.
Which best explains this statement?
A. The service is provided in the natural
environment of people.
B. The nurse has to conduct community
diagnosis to determine nursing needs and
problems.
C. The services are based on the
available resources within the community.
D. Priority setting is based on the
magnitude of the health problems
identified.
3. Population-focused nursing practice
requires which of the following processes?
A. Community organizing
B. Nursing process
C. Community diagnosis
D. Epidemiologic process
4. What other factor must be
considered in determining the occupational
health privileges to which the workers will
be entitled?
A. Type of occupation: agricultural,
commercial, industrial
B. Location of the workplace in relation to
health facilities
C. Classification of the business enterprise
based on net profit
D. Sex and age composition of employees
SITUATION: Field health services and
information system provides summary data
on health service delivery and selected
program from the barangay level up to the
national level. As a nurse, you should
know the process on how this information
became processed and consolidated.
5. All of the following are objectives of
FHSIS Except?
A. To complete the clinical picture of
chronic disease and describe their natural
history
B.To provide standardized, facility level
data accurate and are disseminated in a
timely and easy to use fashion
C. To minimize recording and reporting
burden allowing more time for patient care
and promotive activities
D. To ensure that data reported are
useful and accurate and are disseminated
in timely and easy to use fashion
6. What is the fundamental block or
foundation of the field health service
information system?
A. Family treatment record
B. Target Client list
C.Reporting forms
D.Output record
7. What is the primary advantage of having
a target client list?
A. Nurses need not to go back to FTR to
monitor treatment and services to
beneficiaries thus saving time and effort B.
Help monitor service rendered to clients in
general
C. Facilitate monitoring and supervision of
services
D. Facilitate easier reporting
8. Which of the following is used to monitor
particular groups that are qualified as
eligible to a certain program of the DOH?
A. Family treatment record
B. Target Client list
C. Reporting forms
D. Output record
9. In using the tally sheet, what is the
recommended frequency in tallying activities
and services? A. Daily
B. Weekly
C.Monthly
D. Quarterly
10. After bringing the reportin unig forms in
the right facility for processing, Nurse Budek
knew that the output reports are solely
produced by what office? A Rural health
office
B. FHSIS Main office
C. Provincial health office
D. Regional health office
SITUATION: Community organizing is a
process by which people, health services
and agencies of the community are brought
together to act and solve their own
problems.
11. Mang ambo approaches you for
counseling. You are an effective counselor if
you
A. Give good advice to Mang Ambo
B. Identify Mang Ambo's problems C.
Convince Mang Ambo to follow your
advice
D. Help Mang Ambo identify his problems
12. As a newly appointed PHN instructed to
organize Barangay Baritan, which of the
following is your initial step in organizing the
community for initial action?
A. Study the Barangay Health statistics and
records
B. Make a courtesy call to the Barangay
Captain
C. Meet with the Barangay Captain to make
plans
D. Make a courtesy call to the Municipal
Mayor
13. Preparatory phase is the first phase in
organizing the community. Which of the
following is the initial step in the preparatory
phase? A. Area selection
B. Community profiling
C. Entry in the community
D. Integration with the people
14. The most important factor in
determining the proper area for community
organizing is that this area should
A. Be already adopted by another
organization
B. Be able to finance the projects
C. Have problems and needs assistance D.
Have people with expertise to be
developed as leaders
15. Which of the following dwelling place
should the Nurse choose when integrating
with the people?
A. A simple house in the border of Barangay
Baritan and San Pablo
B. A simple house with fencing and gate
located in the center of Barangay Baritan
C. A modest dwelling place where people
will not hesitate to enter
D. A modest dwelling place where people
will not hesitate to enter located in the
center of the community
16. In choosing a leader in the
community during the Organizational
phase, which among these people will
you choose? A. Miguel Zobel, 50 years
old, Rich and
Famous
B. Rustom, 27 years old, Actor C. Mang
Ambo, 70, Willing to work for the desired
change
D. Ricky, 30 years old, Influential and
Willing to work for the desired change
17. Which type of leadership style should
the leaders of the community practice?
A. Autocratic
B. Democratic
C. Laissez Faire
D. Consultative
18. Setting up Committee on Education and
Training is in what phase of COPAR?
A. Preparatory
B. Organizational
C. Education and Training
D. Intersectoral Collaboration
E. Phase out
19. Community diagnosis is done to come
up with a profile of local health situation that
will serve as basis of health programs and
services. This is done in what phase of
COPAR?
A. Preparatory
B. Organizational
C. Education and Training
D. Intersectoral Collaboration
E. Phase out
20. The people named the community
health workers based on the collective
decision in accordance with the set criteria.
Before they can be trained by the Nurse,
The Nurse must first
A. Make a lesson plan
B. Set learning goals and objective
C. Assess their learning needs
D. Review materials needed for training
21. Nurse Budek is conducting a health
teaching to Agnesia, 50-year-old breast
cancer survivor needing rehabilitative
measures. He knows that health education
is effective when
A. Agnesia recites the procedure and
instructions perfectly
B. Agnesia's behavior and outlook in
life was changed positively
C. Agnesia gave feedback to Budek
saying that she understood the instruction
D. Agnesia requested a written instruction
from Budek
22. Which of the following is true about
health education?
A. It helps people attain their health through
the nurse's sole efforts
B. It should not be flexible
C. It is a fast and mushroom like process D.
It is a slow and continuous process.
23. Which of the following factors least
influence the learning readiness of an
adult learner? A. The individual's stage of
development B. Ability to concentrate on
information to be learned
C. The individual's psychosocial
adaptation to his illness
D. The internal impulses that drive the
person to take action
24. Which of the following is the most
important condition for diabetic patients to
learn how to control their diet?
A. Use of pamphlets and other
materials during instructions B.
Motivation to be symptom free C.
Ability of the patient to understand
teaching instruction D. Language used 29. If Regielyn will compute for the monthly
by the nurse doses of OPV, she will have which of
the following:
25. An important skill that a primigravida A. 115
has to acquire is the ability to bathe her B. 198 C. 151
newborn baby and clean her breast if she D. 132
decides to breastfeed her baby, which of the
following learning domain will you classify 30. Compute for the monthly doses'
the above goals? requirement for Hepatitis B vaccine:
A. Psychomotor A. 130 B. 151
B. Cognitive C. 132
C. Affective D. 115
D. Attitudinal
Situation: According to study,
Situation: Community health nurse Regielyn environmental health as well as
will administer immunization to children in environmental sanitation is still a concern
her assigned community. The total and a problem in our country.
population of Barangay Sta. Mesa is 15,750
people. The right distribution depends on 31. The Department of Health through
the availability of vaccines and the Environmental and Occupational Health
appropriate health personnel. Office has authority to act on all issues
related to environment and health. Nurse
26. Regielyn is required to have her Francis is aware that diarrheal diseases
monthly doses for Tetanus Toxoid (TT). ranked first as the leading cause of disease
She will come up with which of the following among general population. The
choices: comprehensive sanitation code of the
A 79 Philippines is mandated and put into law
B. 198 as:
C. 99 A. PD 825
D. 153 B. RA 8749 C. PD 856
D. RA 9275
27. What will be the eligible population for
Hepa, B vaccine? 32. Neil, a newly hired public health worker
A. 551 B. 550 C. 472 is no working in his assigned
D. 473 community, Barangay Bidin, in a remote
area under the Municipality of Sibutu.
28. Compute for the monthly doses of Anti- During his community assembly, he
Measles Vaccine: emphasized that their different types of
A. 79 toilets that are being utilized in the said
B. 130 barangay. The EHS set policies on
C. 99 approved types of toilets and
D. 68 categorizing them according to different
levels. Neil has correct understanding
regarding toilet level - Il if he states that.
 A. "Level I is a non-water carriage toilet
facility; no water is necessary to wash
the waste into the receiving space this
include pit latrines
B "Level Il is a type of toilet facility requiring
small amount of water to wash the waste
into the receiving space like pour flush'
C. "Level Il is a water carriage type of toilet
facility that is connected to a septic tank
and to a sewerage system to treatment
plant"
D "Level I is an on-site toilet facility of a
water carriage type with water-sealed and
flush type with septic tank"
33. The Department of Health (DOH)
through the EOHO has set some policies on
the following areas such as (1) approved
types of water facilities (2) Unapproved
types of water facilities (3) Access to safe
and potable drinking water (4) water quality
and monitoring surveillance and (5)
waterworks system and well construction.
Leila, knows that Level I approved type of
water supply facility include all of the
following choices apart from one that is
incorrect:
A. Designed to deliver 40 - 80 liters of
water, to an average of 100 households,
with one faucet per 4-6 households B.
Suitable for rural areas where houses are
clustered densely to justify a simple piped
system.-
C. Communal Faucet System or Stand -
Posts, a system composed of a source, a
reservoir, a piped distribution network and
a communal faucet, located not more than
25 meters from the farthest house D. A
protected well or a developed spring with
an outlet but without distribution system,
generally adaptable for rural areas where
the house is thinly scattered.
34. There are 4 rights in food safety. These
rights involve the chain in food processing
from the source in the market until the food
reaches the table. Neil, knows that all are 4
rights in food safety except:
A Right Source
B. Right Cooking
C. Right Food
D. Right Storage
35. The modern-day practice of water
supply among urban areas is through water
refilling station. Andy Lynn, as an owner of a
water refilling distilled station knows that
she has to regularly monitor the quality of
drinking water being sold in her station, if
she will submit her water for analysis for
physical and chemical properties, it should
be submitted every how many months:
A. Every month
B. Every 6 months
C. Annually
D. As need arises
36. Which of the following statements are
true?
A. All communicable diseases are
infectious and contagious.
B. All contagious diseases are
infectious but not all infectious are
contagious. C. Communicable diseases are
all contagious but not infectious.
D.Infectious diseases are contagious and
also communicable.
37. An organism that is capable of invading
and multiplying in the body of the host:
A. Causative Agent
B. Reservoir
C. Bacteria
D. Carrier
38. The infecting ability of a
microorganism depends on its degree of:
A. Pathogenicity
B. Communicability
C. Teratogenicity
D. Epidemiology
39. Amazingly, patients with malaria have a
cycle of cold, hot and diaphoretic stage.
Fever is evident in a particular period of
time and not all through the disease process
because:
A. During febrile stage toxins are
present.* B. During febrile stage, the
microorganisms simultaneously
reproduce .
C. During febrile stage, iron is
sequestered by the liver.
D. During febrile stage, the
gametocytes are produced.
40. A diagnostic procedure that is a must
in every case of Malaria in a certain
community: A. Malarial Blood Smear
B. Quantitative Buffy Coat
C. ELISA
D. Nocturnal Blood Examination
41. The drug of choice against malaria is:
A. Chloroquine
B. N-diethyl-D-toluamide
C. Pyethrinoids
D. Biltricide
42. Blood Schizonticides are given with the
following dose:
A. Given at a dose of 10 mg/kg once a
day for two days, then 5rg/kg single dose
on the third day.
B. Given at a dose of 5 mg/kg once a
day for two days, then 10 mg/kg single
dose on the third day
C. Given at a dose of 10 mg/kg twice a
day for two days, then 5mg/kg single dose
on the third day
D. Given at a dose of 5 mg/kg twice a
day for two days, then 5mg/kg single dose
on the third day
43. Which of the following health teachings
will be included if the patient is taking
chloroquine?
A. Advise patient that the urine may turn
rust brown in color. B. It should be given
before meals.
C. Can be giiven even before c and S is
completed or confirmed.
D. Frequent ambulation is required
when taking the medication.
44. Which of the following manifestations of
the client, that according to WHO, may lead
to definitive diagnosis of Dengue
Hemorrhagic fever, except:
A. Fever lasting 2-7 days
B. Thrombocytopenia
C. Positive tourniquet test plus petechiae,
ecchymoses, purpura
D.Abdominal pain plus joint fever
45. In what stage is Herman's sign
clinically manifested by the client? A
Febrile stage
B.Hemorrhagic Stage
C. Circulatory failure stage
D. Hypovolemic Shock
46. A child is admitted to the pediatric unit
with a diagnosis of suspected
meningococcal meningitis. Which of the
following nursing measures should the
nurse do FIRST?
A. Institute seizure precautions
B.Assess neurologic status
C. Place in respiratory isolation
D. Assess vital signs
 47. A client is diagnosed with methicillin
resistant staphylococcus aureus
pneumonia. What type of isolation is
MOST appropriate for this client? A.
Reverse isolation
B. Respiratory isolation
C. Standard precautions
D. Contact isolation
48. Several clients are admitted to an adult
medical unit. The nurse would ensure
airborne precautions for a client with which
of the following medical conditions? A. A
diagnosis of AIDS and cytomegalovirus B.
A positive PPD with an abnormal chest x-
ray
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung
49. Which of the following is the FIRST
priority in preventing infections when
providing care for a
A. Hand washing
B. Wearing gloves
C. Using a barrier between client's furniture
and nurse's bag D. Wearing gowns and
goggles
50. An adult woman is admitted to an
isolation unit in the hospital after
tuberculosis was detected during a pre-
employment physical. Although frightened
about her diagnosis, she is anxious to
cooperate with the therapeutic regimen.
The teaching plan includes information
regarding the most common means of
transmitting the tubercle bacillus from one
individual to another. Which contamination
is usually responsible?
A. Hands B.
Droplet nuclei.
C.Milk products.
D.Eating utensils
51. A nurse is describing the process of
fetal circulation to a client during a prenatal
visit. The nurse accurately tells the client
that fetal circulation consists of:
A. Two umbilical veins and one
umbilical artery
B. Two umbilical arteries and one
umbilical vein
C. Arteries carrying oxygenated blood
to the fetus
D. Veins carrying deoxygenated blood
to the fetus
52. A nurse prepares to assess a fetal
heartbeat. The nurse uses a fetoscope,
knowing that the fetal heartbeat can first be
heard with a fetoscope at gestational week:
A. 5
B. 10 C. 16
D. 20
53. A nurse is performing an
assessment of a primipara who is being
evaluated in a clinic during her second
trimester of pregnancy. Which of the
following indicates an abnormal physical
finding necessitating further testing?
A. Consistent increase in fundal height
B. Fetal heart rate of 180 beats per
minute
C. Braxton hicks' contractions
D. Quickening
54. A nurse is performing an
assessment of a pregnant client who is at
28 weeks of gestation. The nurse
measures the fundal height in centimeters
and expects the findings to be which of the
following?
A.22 cm
B.28 cm
C.36 cm
D.40 cm
55. A pregnant client asks the nurse in
the clinic when she will be able to start
feeling the fetus move. The nurse responds
by telling the mother that fetal movements
will b noted between: A. 6 and 8 weeks of
gestation
B.8 and 10 weeks of gestation
C.10 and 12 weeks of gestation
D. 14 and 16 weeks of gestation
56. A clinic has instructed a pregnant client
in measures to prevent varicose veins
during pregnancy. Which statement if made
by the client indicates a need for further
education?
A. "I should wear support hose" B. "I
should be wearing flat nonslip shoes that
have an arch support*
C. "I should wear pantyhose"
D. "I can wear knee-high hose as long as I
don't leave them on longer than 8 hours.
57. The nurse is providing care for a
postpartum client. Which of the following
condition would place this client at greater
risk for a postpartum hemorrhage?
A Hypertension
B. Uterine infection
C. Placenta previa
D Severe pain
58. During the 3'd postpartum day, which of
the following would the nurse be most likely
to find in the client?
A. She's interested in learning more
about newborn care
B. She talk a lot about her birth
experience C. She sleeps whenever the
baby isn’t present
D. She requests help in choosing a name
for the baby
59. A client in the active phase of labor has
a reactive fetal monitor strip and has been
encouraged to walk. When she returns to
bed for a monitor check, she complains of
an urge to push. When performing a vaginal
examination, the nurse accidentally ruptures
the amniotic membranes, and as she
withdraws her hand, the umbilical cord
comes out. What should the nurse do next?
A. Put the client in a knee-to-chest position
B. Call the physician or midwife
C. Push down on the uterine fundus D.
Set up for a fetal blood sampling to
assess for fetal acidosis
60. The nurse can consider the fetus's head
to be engaged when:
A. The presenting part moves through
the pelvis
B. The fetal head rotates to pass
through the ischial spines
C. The fetal head extends as it passes
under the symphysis pubis
D. The biparietal diameter passes the
pelvic inlet
61. A client is experiencing a true labor
when her contraction pattern shows
A. Occasional irregular contractions B.
Irregular contractions that increase in
intensity
C. Regular contractions that remain the
same
D. Regular contractions that increase in
frequency and duration
62. When late decelerations are noted
by the nurse, the first action is to: A.
Notify the physician STAT
B. Position the client on her left side
C. Administer oxygen via face mask D.
Increase the drip rate of the intravenous
fluid
63. A client is receiving magnèsium sulfate
to help suppress preterm labor. The nurse
should watch for which sign of magnesium
toxicity.
A. Headache
B. Loss of deep tendon reflexes
C. Palpitations
D. Dyspepsia
64. During prenatal screening of a diabetic
client, the nurse should keep in mind that
the client is at increased risk for:
A. Rh incompatibility
B. Placenta previa
C. Hyperemesis
D. Stillbirth
65. Which of the following is a
normal physiological response in the
early postpartum period? A. Urinary
urgency
B. Rapid diuresis
C. Decrease in blood pressure
D.Increased motility of the Gl system
66. A newly pregnant client who is a little
overweight ask how much weight she
should gain over the 9 months. The most
appropriate answer is;
A. "For your size a little heavy, about
15 pounds would be best
B. "It really doesn't matter exactly how
much weight you gain, as long as your diet
is healthy.
C. "A gain of about 24-25 pounds is
best for mother and baby. Sure ni? Oo na
search ni nako
D. "Because you are a little overweight,
it would be best for you not to gain too
much weight.----
67. A parent brings a 19-month-old toddler
to the clinic for a well-child checkup. When
palpating the toddler's fontanels, the nurse
would expect to find:
A. Closed anterior fontanel and open
posterior fontanel.----
B. Open anterior fontanel and closed
posterior fontanel.--- dapat Kani mn ata
C. Closed anterior and posterior
fontanels. Kani sure? Oo kani pud D.
Open anterior and posterior fontanels.
68. An infant is diagnosed with patent
ductus arteriosus. Which of the following
drugs may be administered in hopes of
achieving pharmacologic closure of the
defect? A. Digoxin (Lanoxin)
B. Prednisone
C. Furosemide (Lasix)
D. Indomethacin (Indocin)
69. The nurse is teaching a mother about
the benefits of breast-feeding her infant.
Which type of immunity is passed on to the
infant during breast-feeding? A Natural
immunity
B Natural acquired active immunity
C. Naturally acquired passive immunity
D. Artificially acquired active immunity
70. The nurse would anticipate a possible
complication in infants delivered by
cesarean section. This condition would be:
A. Respiratory distress
B Renal impairment
C AB incompatibility
D. Kernicterus
71. An 11 lb. 6 oz. baby girl was delivered
by cesarean section to a diabetic mother.
The priority assessment of the infant of a
diabetic mother would be for;
A. Hypoglycemia
B. Sepsis
C. Hyperglycemia
D. Hypercalcemia
72. During a physical exam of an infant with
congenital hip dysplasia, the nurse would
observe and report which of the following
characteristics?
A. Symmetrical gluteal folds
B. Limited adduction of the affected leg C.
Femoral pulse when the hip is flexed and
the leg is abducted
D. Limited abduction of the affected leg
73. The nurses caring for a premature baby
use careful hand washing techniques
because they know premature infants are
more susceptible to infection than full-term
infants. Which of the following explains why
premature infants are more likely to develop
infection?
A. Their liver enzymes are immature B.
Premature babies may receive steroid
drugs, which affects the immune system
C. Premature infants receive few
antibodies from the mother, because
antibodies pass across the placenta
during the last month of pregnancy
D. Surfactant is decreased in premature
infants
74. In the delivery room, a client has just
delivered a healthy 7-pound baby boy. The
physician instructs the nurse to suction the
baby. The procedure that the nurse would
use is to:
A. Suction the nose first
B Suction the mouth first
C. Suction neither the nose nor mouth
until the physician gives further
instructions D. Turn the baby on his side
so mucus will drain out before suctioning
75. A mother tells the nurse that her 22-
month-old child says "no" to everything.
When scolded, the toddler becomes angry
and starts crying loudly, but then
immediately wants to be held. What is the
best interpretation of this behavior?
A. The toddler isn't effectively coping
with stress.
B. The toddler's need for affection isn't
being met.
C. This is normal behavior for a 2-year-
old child.
D. This behavior suggests the need for
counseling.
76. Which nursing intervention has priority
when feeding an infant with a cleft lip or
palate?
A. Directing the flow of milk in the center of
mouth
B. Providing small, frequent feedings
C. Avoiding breast-feeding
D. Infrequent burping
77. Which action best explains the main
role of surfactant in the neonate?
A. Assist with ciliary body maturation in
the upper airways
B. Helps maintain a rhythmic breathing
pattern
C. Promotes clearing mucus from the
D. Helps the lungs remain expanded atter
the initiation of breathing
78. While assessing a 2-hour-old neonate,
the nurse observes the neonate to have
acrocyanosis. Which of the following
nursing actions should be performed
initially?
A. Activate the blue code or
emergency system
B. Do nothing because acrocyanosis
is normal in the neonate C. Immediately
take the neonate's temperature according
to hospital policy D. Notify the physician of
th e need for a cardiac consult
79. When performing a neurologic
assessment, which sign is considered a
normal finding in a neonate?
A. Doll eyes
B. "Sunset eyes
C. Positive Babinski's sign
D. Pupils that don't react to light
80. A client's mother asks the nurse why
her newborn grandson is getting an
injection of vitamin K. Which best explains
why this drug is given to neonates? A.
Vitamin K assists with coagulation
B. Vitamin K assists the gut to mature
C. Vitamin K initiates the immunization
process
D. Vitamin K protects the brain from excess
fluid production
81. Respiratory depression in neonates that
is due to maternal use of narcotics is given
a narcotic antagonist which is Naloxone
(Narcan) through IM. What is the other route
for administering Narcan?
A ID
B. Tropical
C. Oral
D. Umbilical Vessel
82. During assessment of a newborn, what
is the 1st sign of obstruction or respiratory
compromise?
A Increasing RR
B. Increasing PR
C. Increasing BUN
D. Increasing Creatinine
83. A newborn that has no audible
heartbeat is being resuscitated in the
delivery room. After 30 seconds of CPR the
heart rate is 70 bpm. The next action of the
nurse would be to? A. Administer 0.5 ml/kg
of epinephrine
B. Administer 1ml/kg of epinephrine
C Administer 0.3ml/kg of epinephrine
D. Do nothing
84. Resuscitation in a newborn may cause
many side effects including hypovolemia.
Which of the following is not included of the
signs and symptoms? A. Hypotension
B. Bradycardia
C. Decrease CVP
D. Decrease peripheral tissue perfusion*
85. A nurse in a delivery room is assisting
with the delivery of a newborn infant. After
the delivery, the nurse prepares to prevent
heat loss in the newborn resulting from
evaporation by:
A Warming the crib pad
B. Turning on the overhead radiant warmer
C Closing the doors to the room
D. Drying the infant in a warm blanket
86. In regulating the temperature of the
newborn which of the following action of the
nurse requires further attention? A. Wiping
the newborn dry B. Placing newborn under
a prewarmed radiant warmer
C. Initiating skin-skin contact
D. Placing newborn on X-ray tables
87. Radiant heat warmers are open beds
with overhead radiant source used in
regulating the newborns' temperature. It
contains a probe which is tape in what site?
A Head
B. Xiphoid Process?*
C. Upper extremities
D. Lower extremities
88. Asphyxia is a condition arising when
the body is deprived of oxygen, infants
who have this condition usually receive IF
to prevent exhaustion. Furthermore, an
infant who also is tachypneic receives
gavage feeding which also needs to be
given a pacifier at feeding times. Which of
the following is a contraindication in giving
a pacifier?
A NEC
B. Good sucking reflex
C. Intussusception
D. TEF
89. A pregnant woman's blood test
revealed a very low hemoglobin level. The
physician considers the woman severely
anemic. Which of the following is the most
likely effect on the fetus if the woman is
severely anemic during pregnancy? A.
Hemorrhage could be possiblel
B. Erythroblastosis fetalis
C. Small for Gestational Age (SGA) baby
D. Large for Gestational Age (LGA) fetus
90. Small for Gestational Age infants fall
below 10TH percentile of the normal weight.
Which of the following will you assess in
these infants? A Good skin turgor
B Normal Liver
C. Large head
D. Intact skull sutures
91. Why are small for gestational age
newborns are at risk for difficulty
maintaining body temperature?
A. They are preterm so are born
relatively in small size
B. They are more active than usual so
throw off covers
C. They do not have as many fat store
as other infants
D. Their skin is more susceptible to
conduction of cold
92. This is the blueness of extremities
observed in Small for Gestational Infants.
A. Acrocyanosis B.
Cyanosis
C. Hemosiderosis
D. Kernicterus
93. Baby girl Gretch was born large for
gestational age. After being delivered
vaginally, this infant should be carefully
assessed for:
A. Increased intracranial pressure
B. Hypothermia
C. Decreased red blood levels (Anemia)
D. Hyperglycemia
94. There are many conditions associated
with macrosomic infants, which of the
following refers to an overgrowth disorder?
A. PDA
B. Omphalocele
C. Beckwith-Wiedemann Syndrome
D. DM
95. What is the preferred birthing type for
LGA infants?
A Normal Spontaneous Vaginal Delivery
B. Forceps Delivery
C Assisted Delivery
D. Cesarean Section
96. A cardiovascular dysfunction that
happens to GA infants that involves a group
of congenital heart defects involving an
abnormal spatial arrangement of any of the
great vessels. A. PDA**
B. Tetralogy of fallot
C. Transposition of great vessels*
D. CHF
97. Neonates of mothers with diabetes are
at risk for which complication following
birth?
A. Atelectasis
B. Microcephaly
C. Pneumothorax
D. Macrosomia
98. In infants with DM mothers, what
happens to their insulin needs at birth?
A Increase
B. Decrease
C Normalize
D. Fluctuates
99. The nurse is aware that a neonate of
a mother with diabetes is at risk for what
complication? A. Anemia
B. Hypoglycemia
C. Nitrogen loss
NP 3
1.The nurse suspects that her client is in
cardiac arrest. According to the American
Heart Association, the nurse should perform
the actions listed below. Order these actions
in the sequence that the nurse should
perform them.
I. Activate the emergency medical system.
II. Assess responsiveness.
III. Call for a defibrillator.
IV. Provide two slow breaths. V.
Assess pulse.
VI. Assess breathing.
A. 213645
B. 132456
C. 1,2,3,6,5,4
D. 2,3.1,5,6,4
2. A client comes to the ER complaining of
chest pain. An electrocardiogram (ECG)
reveals myocardial ischemia and an anterior
wall myocardial infarction (MI). Which ECG
characteristics indicates myocardial
ischemia?
A. Prolonged PR interval
B. Absent Q wave
C. Elevated ST Segment
D.Widened QRS complex
3. Nyosh admits himself on the ER
following an intense chest pain and the
D.Thrombosis
100. A preterm infant is those born
before the end of week 37 of gestation
and what another criterion? A. Weight
>2,500 g (5 1b 8oz)
B. Weight < 2,500 g (5 Ib 8 oz)
C. Weight < 2,500 g (8 lb 5 oz)
D.Weight > 2,500 g (8lb 5oz)
doctor orders an ECG. The result below will
be interpreted
as
A. AV bundle block
B. Sinus rhythm
C. Atrial flutter
D. Sinus arrhythmia
4. The electrocardiogram (ECG) tracing
shown below, excluding the seventh beat,
has a normal QRS complex, one premature
atrial contraction (PAC), and what other
attributes?
A. P wave is identifiable, PR is 0.16 second,
and sinus rhythm is at 95 beats/minute.
B. P wave and PR interval are unidentifiable
and sinus arrhythmia is at 95
beats/minute.
C. P wave is identifiable, PR interval is 0.16
second, and sinus rhythm is at 95
beats/minute.
D. P wave is identifiable, PR interval is
0.16 second, and sinus arrhythmia is at
95 beats/minute. //Way sure ni
 5. A client who is awake and diaphoretic
has a palpable pulse. The nurse runs an
electrocardiogram (ECG) strip, which
reveals the following pattern for the lead I.
What does the pattern indicate?
A. Normal sinus rhythm
B. Atrial fibrillation
C. Ventricular standstill
D. Ventricular tachycardia
6. Mrs. Chua a 78-year-old client is
admitted with the diagnosis of mild chronic
heart failure. The nurse expects to hear
when listening to client's lungs indicative of
chronic heart failure would be:
A. Stridor
B. Crackles
C. Wheezes
D. Friction rubs
7. Patrick who is hospitalized following a
myocardial infarction asks the nurse why he
is taking morphine. The nurse explains that
morphine
A. Decrease anxiety and restlessness
B. Prevents shock and relieves pain
C. Dilates coronary blood vessels
D. Helps prevent fibrillation of the heart
8. Which of the following should the nurse
teach the client about the signs of digitalis
toxicity?
A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back D.
Visual disturbances such as seeing
yellow spots
9. Nurse Trisha teaches a client with heart
failure to take oral Furosemide in the
morning. The reason for this is to help…
A. Retard rapid drug absorption B.
Excrete excessive fluids accumulated at
night
C. Prevents sleep disturbances during night
D. Prevention of electrolyte imbalance
10. What would be the primary goal of
therapy for a client with pulmonary edema
and heart failure?
A. Enhance comfort
B. Increase cardiac output
C. Improve respiratory status
D. Peripheral edema decreased
11. Nurse Linda is caring for a client with
head injury and monitoring the client with
decerebrate posturing. Which of the
following is a characteristic of this type of
posturing?
A. Upper extremity flexion with lower
extremity flexion
B. Upper extremity flexion with lower
extremity extension
C. Extension of the extremities after a
stimulus
D. Flexion of the extremities after stimulus
7. A female client is taking Cascara
Sagrada. Nurse Betty informs the client that
the following maybe experienced as side
effects of this medication: A. GI bleeding
B. Peptic ulcer disease
C. Abdominal cramps
D. Partial bowel obstruction
8. Dr. Marquez orders a continuous
intravenous nitroglycerin infusion for the
client suffering from myocardial infarction.
Which of the following is the most essential
nursing action?
A. Monitoring urine output frequently
B. Monitoring blood pressure every 4 hours
C. Obtaining serum potassium levels daily
D. Obtaining infusion pump for the
medication
 9. During the second day of hospitalization
of the client after a Myocardial Infarction.
Which of the following is an expected
outcome?
A. Able to perform self-care activities
without pain
B. Severe chest pain
C. Can recognize the risk factors of
Myocardial Infarction
D. Can Participate in cardiac rehabilitation
walking program
10. A 68-year-old client is diagnosed with a
right-sided brain attack and is admitted to
the hospital. In caring for this client, the
nurse should plan to:
A. Application of elastic stockings to prevent
flaccid by muscle
B. Use hand roll and extend the left upper
extremity on a pillow to prevent
contractions
C. Use a bed cradle to prevent dorsiflexion
if feet
D. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a
client who has returned to the nursing unit
after left nephrectomy. Nurse Liza’s
highest priority would be… A. Hourly
urine output
B. Temperature
C. Able to turn side to side
D. Able to sips clear liquid
12. A 64-year-old male client with a long
history of cardiovascular problem including
hypertension and angina is to be scheduled
for cardiac catheterization. During pre
cardiac catheterization teaching, Nurse
Cherry should inform the client that the
primary purpose of the procedure is…
A. To determine the existence of CHD
B. To visualize the disease process in
the coronary arteries C. To obtain the
heart chambers pressure D. To measure
oxygen content of different heart
chambers
13. During the first several hours after
a cardiac catheterization, it would be
most essential for nurse Cherry to…
A. Elevate client's bed at 45° B.
Instruct the client to cough and deep
breathe every 2 hours
C. Frequently monitor client's apical pulse
and blood pressure
D. Monitor client’s temperature every hour
14. Kate who has undergone mitral valve
replacement suddenly experiences
continuous bleeding from the surgical
incision during postoperative period. Which
of the following pharmaceutical agents
should Nurse Aiza prepare to administer to
Kate?
A. Protamine Sulfate
B. Quinidine Sulfate
C. Vitamin C
D. Coumadin
15. In reducing the risk of endocarditis,
good dental care is an important measure.
To promote good dental care in client with
mitral stenosis in teaching plan should
include proper use of… A. Dental floss
B. Electric toothbrush
C. Manual toothbrush
D. Irrigation device
16. Among the following signs and
symptoms, which would most likely be
present in a client with mitral regurgitation?
A. Altered level of consciousness
B. Exceptional Dyspnea C. Increase
creatine phospholinase
concentration
D. Chest pain
 17. Kris with a history of chronic infection of
the urinary system complains of urinary
frequency and burning sensation. To figure
out whether the current problem is in renal
origin, the nurse should assess whether the
client has discomfort or pain in the…
A. Urinary meatus
B. Pain in the Labium
C. Suprapubic area
D. Right or left costovertebral angle
18. Nurse Perry is evaluating the renal
function of a male client. After documenting
urine volume and characteristics, Nurse
Perry assesses which signs as the best
indicator of renal function.
A. Blood pressure
B. Consciousness
C. Distension of the bladder
D. Pulse rate
19. John suddenly experiences a
seizure, and Nurse Gina notice that John
exhibits uncontrollable jerking
movements. Nurse Gina documents that
John experienced which type of seizure?
A. Tonic seizure
B. Absence seizure
C. Myoclonic seizure
D. Clonic seizure
20. Smoking cessation is critical strategy for
the client with Burgher's disease, Nurse
Jasmin anticipates that the male client will
go home with a prescription for which
medication? A. Paracetamol B. Ibuprofen
C. Nitroglycerin
D. Nicotine (Nicotrol)
21. Which of the following lab studies
should be done periodically if the client is
taking warfarin sodium (Coumadin)? A.
Stool specimen for occult blood
B. White blood cell count
C. Blood glucose
D. Erythrocyte count
22. A client is admitted with a diagnosis
of polycythemia vera. The nurse should
closely monitor the client for: A.
Increased blood pressure
B. Decreased respirations
C. Increased urinary output
D. Decreased oxygen saturation
23. The doctor has prescribed a diet high in
vitamin B12 for a client with pernicious
anemia. Which foods are highest in vitamin
B12?
A. Meat, eggs, dairy products
B. Peanut butter, raisins
C. Broccoli, cauliflower, cabbage
D. Shrimp, legumes, bran cereals
24. Which of the following arteries
primarily feeds the anterior wall of the
heart? A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery
25. When do coronary arteries
primarily receive blood flow? A. During
inspiration
B. During diastole
C. During expiration
D. During systole
26. Which of the following illnesses is
the leading cause of death in the US?
A. Cancer
B. Coronary artery disease
C. Liver failure
D. Renal failure
27. Which of the following conditions most
commonly results in CAD?
A. Atherosclerosis
B. DM
C. MI
D. Renal failure
28. Atherosclerosis impedes coronary
blood flow by which of the following
mechanisms?
A. Plaques obstruct the vein
B. Plaques obstruct the artery
C. Blood clots form outside the vessel wall
D. Hardened vessels dilate to allow the
blood
29. Which of the following risk factors for
coronary artery disease cannot be
corrected?
A. Cigarette smoking
B. DM
C. Heredity
D. HPN
30. Exceeding which of the following serum
cholesterol levels significantly increases the
risk of coronary artery disease?
A. 100 mg/dl
B. 150 mg/dl
C. 175 mg/dl
D. 200 mg/dl
31. Which of the following actions is the first
priority care for a client exhibiting signs and
symptoms of coronary artery disease? A.
Decrease anxiety
B. Enhance myocardial oxygenation
C. Administer sublingual nitroglycerin
D. Educate the client about his symptoms
32. Medical treatment of coronary
artery disease includes which of the
following procedures? A. Cardiac
catheterization
B. Coronary artery bypass surgery
C. Oral medication administration D.
Percutaneous transluminal coronary
angioplasty are invasive, surgical
treatments.
33. Prolonged occlusion of the right
coronary artery produces an infarction in
which of the following areas of the heart?
A. Anterior
B. Apical
C. Inferior
D. Lateral
34. After an anterior wall myocardial
infarction, which of the following problems is
indicated by auscultation of crackles in the
lungs?
A. Left-sided heart failure
B. Pulmonic valve malfunction C.
Right-sided heart failure
D. Tricuspid valve malfunction
35. Which of the following diagnostic tools
is most commonly used to determine the
location of myocardial damage?
A. Cardiac catheterization
B. Cardiac enzymes
C. Echocardiogram
D. Electrocardiogram
36. What is the first intervention for a client
experiencing myocardial infarction?
A. Administer morphine
B. Administer oxygen
C. Administer sublingual nitroglycerin
D. Obtain an electrocardiogram
37. What is the most appropriate nursing
response to a myocardial infarction client
who is fearful of dying?
A. “Tell me about your feeling right now.”
B. “When the doctor arrives, everything will
be fine.”
C. "This is a bad situation, but you'll feel
better soon.”
D. “Please be assured we're doing
everything we can to make you feel better.”
38. Which of the following classes of
medications protects the ischemic
myocardium by blocking catecholamines
and sympathetic nerve stimulation? A.
Beta-adrenergic blockers
B. Calcium channel blockers
C. Narcotics
D. Nitrates
39. What is the most common complication
of a myocardial infarction?
A. Cardiogenic shock
B. Heart failure
C. Arrhythmias
D. Pericarditis
40. With which of the following disorders is
jugular vein distention most prominent?
A. Abdominal aortic aneurysm
B. Heart failure
C. Myocardial infarction
D. Pneumothorax
41. What position should the nurse place
the head of the bed in to obtain the most
accurate reading of jugular vein distention?
A. High-Fowler's
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
42. Which of the following parameters
should be checked before administering
digoxin? A. Apical pulse
B. Blood pressure
C. Radial pulse
D. Respiratory rate
43. Toxicity from which of the following
medications may cause a client to see a
green halo around lights?
A. Digoxin
B. Furosemide
C. Metoprolol
D. Enalapril
44. Which of the following symptoms is
most commonly associated with left-sided
hear failure? A. Crackles
B. Arrhythmias
C. Hepatic engorgement
D. Hypotension
45. In which of the following disorders
would the nurse expect to assess sacral
edema in bedridden client? A. DM
B. Pulmonary emboli
C. Renal failure
D. Right-sided heart failure
46. Which of the following symptoms might
a client with right-sided heart failure exhibit?
A. Adequate urine output
B. Polyuria
C. Oliguria
D. Polydipsia
47. Which of the following classes of
medications maximizes cardiac
performance in clients with heart failure by
increasing ventricular contractility? A.
Beta-adrenergic blockers
B. Calcium channel blockers
C. Diuretics
D. Inotropic agents
48. Stimulation of the sympathetic
nervous system produces which of the
following responses? A. Bradycardia
B. Tachycardia
C. Hypotension
D. Decreased myocardial contractility
 49. A 25-year-old male is admitted in sickle
cell crisis. Which of the following
interventions would be of highest priority for
this client?
A. Taking hourly blood pressures with
mechanical cuff
B. Encouraging fluid intake of at least
200mL per hour
C. Position in high fowlers with knee gatch
raised
D. Administering Tylenol as ordered
a chest tube inserted notes continuous
gentle bubbling in the suction control
chamber. What action is appropriate?
A. Do nothing, because this is an
expected finding.
B. Immediately clamp the chest tube
and notify the physician
C. Check for an air leak because
the bubbling should be intermittent
D. Increase the suction pressure so
that bubbling becomes vigorous

50. A newly admitted client has 53. A nurse has assisted a physician
sickle cell crisis. The nurse is planning with the insertion of a chest tube. The
care based on assessment of the client. nurse monitors the adult client and
The client is complaining of severe pain notes fluctuation of the fluid level in the
in his feet and hands. The pulse water seal chamber after the tube is
oximetry is 92. Which of the following inserted. Based on the assessment,
interventions would be implemented which action would be appropriate?
first? Assume that there are orders for
each intervention: A. Adjust the room A. Inform the physician
temperature B. Continue to monitor the clien t C.
B. Give a bolus of IV fluids Reinforce the occlusice dressing.
C. Start Oxygen D. Encourage the client to deep-
D Administer meperidine breathe
(Demerol) 75mg IV push
54. The nurse is caring for a male
client with a chest tube, turns the client
51. A male client who takes
to the side and the chest tube
theophylline for chronic obstructive
accidentally disconnects. The initial
pulmonary disease is seen in the urgent
nursing action is to:
care center for respiratory distress.
A. Call the physician
Once the client is stabilized, the nurse
B. Place the tube in a bottle of
begins discharge teaching. The nurse
sterile water
would be especially vigilant to include
C. Immediately replace the chest
information about complying with
tube system
medication therapy If the client's baseline
D. Place the sterile dressing ove the
theophylline level was.
disconnection site.
A. 10 mcg/ml
B. 12 mcg/ml C. 15 mcg/ml D. 18
55. Nurse Paul is assisting a
mcg/ml
physician with the removal of a chest
tube. The nurse should instruct the client
52. Nurse Kim is caring for a client
to:
with a pneumothorax and who has had
A. Exhale slowly
 B. Stay very still pulmonary disease Which of the
C. Inhale and exhale quickly following would the nurse expect to note
D. Perform the Valsalva maneuver on assessment of this client?
A. Hypocapnia
56. While changing the tapes on a B. A hyperinflated chest noted on
tracheostomy tube, the male client the chest ray
coughs and the tube is dislodged. The C. Increase oxygen saturation With
initial nursing acting is to: exercise
A. Call the physician to reinsert the D. A widened diaphragm noted on
tube the chest xray
B. Grasp the retention sutures to
spread the opening 60. A community health nurse is
C. Call the respiratory therapy conducting an educational session With
department to reinsert the community members regarding
tracheostomy tuberculosis. The nurse tells the group
D. Cover the tracheostomy wite with that one of the first symptoms
sterile dressing to prevent infection. associated with tuberculosis is:
A. Dyspnea
57. A nurse is caring for a male B. Chest pain
client immediately after removal of the C. A bloody, productive cough D.
endotracheal tube. The nurse reports A cough with the expectoration
which of the following signs immediately Of mucoid sputum
if experienced by the client?
A. Stridor 61 A nurse performs an
B. Occasional, pink-tinged sputum admission assessment on a female client
C. A few basilar lung crackles on With a diagnosis of tuberculosis.
the right The nurse reviews the results of
D. Respiratory rate of 24 breaths/min which diagnostic test that Will confirm this
diagnosis? A Bronchoscopy
58. An emergency room nurse is B Sputum culture
assessing a female client who has C Chest x-ray
sustained a blunt injury to the chest D Tuberculin skin test
wall. Which of these signs would
indicate the presence of a
62 The nursing instructor
pneumothorax in this client?
asks a nursing student to describe the
A. A low respiratory
route of transmission of tuberculosis. The
B. Diminished breathe sounds instructor concludes that the student
C. The presence of a barrel chest understands this Information if the
D. A sucking sound at the site of injury student states that the tuberculosis is
transmitted by:
59. A nurse is caring for a male A. Hand and mouth
client hospitalized with acute
B. The airborne route
exacerbation of chronic obstructive
C. The fecal-oral route
D. Blood and body fluids B Hematuria
C Bronchospasm
63. A nurse is caring for a male client D Blood-streaked sputum
with emphysema who is receiving
oxygen. The nurse assesses the oxygen 67. A nurse is suctioning fluids from a
flow rate to ensure that It does not male client via a tracheostomy tube
exceed. When suctioning, the nurse must
A. 1 L/min limit the suctioning time to a maximum
B 2 L/min of:
C 6 Limin A. 1 minute
D 10 L/min B. 5 seconds
C. 10 seconds
64. A nurse instructs a female client to D. 30 seconds
use the pursed-lip method of breathing
and the client asks the nurse about the 68. A nurse is suctioning fluids from a
purpose of this type of breathing. The female client through an endotracheal
nurse responds, knowing that the tube. During the suctioning procedure,
primary purpose of purSed-lip breathing is the nurse notes on the monitor that the
to: heart rate is decreasing. Which of the
A Promote oxygen intake. following is the appropriate nursing
B Strengthen the diaphragm. intervention?
C Strengthen the intercostal muscles. A Continue to suction.
D. Promote carbon dioxide B. Notify the physician immediately.
elimination. C. Stop the procedure and
reoxygenate the client.
65. Nurse Hannah is preparing to D. Ensure that the suction is limited
obtain a sputum specimen from a client. to 15 seconds
Which of the following nursing actions
will facilitate obtaining the specimen? 69. An unconscious male client is
A. Limiting fluids admitted to an emergency room. Arterial
B. Having the clients take three deep blood gas measurements reveal a pH of
breaths 7.30, a low bicarbonate level, a normal
C. Asking the client to split into the carbon dioxide level, a normal oxygen
collection container level, and an elevated potassium level.
D. Asking the client to obtain the These results indicate the presence of:
specimen after eating A. Metabolic acidosis
B. Respiratory acidosis
66 A nurse is caring for a female client C. Overcompensated respiratory
after a bronchoscopy and biopsy. Which acidosis
of the following signs, if noted in the D. Combined respiratory and
client, should be reported immediately to metabolic acidosis
the physicians?
A. Dry cough
 70 A female client is suspected of
having a pulmonary embolus. A nurse
assesses the client, knowing that which
of the following is a common clinical
manifestation Of pulmonary embolism?
A. Dyspnea
B Bradypnea
C Bradycardia
D Decreased respiratory
71. A nurse teaches a male client
about the use of a respiratory inhaler.
Which action by the client indicates a
need for further teaching?
A. Inhales the mist and quickly
exhales
B. Removes the cap and shakes the
inhaler well before use
C. Presses the canister down with
the finer as he breathes in
D. Waits 1 to 2 minutes between
puffs if more than one puff has
been
prescribed
72. A female client has just returned
to a nursing unit following
bronchoscopy. A nurse would implement
which Of the following nursing
interventions for this client?
A. Administering atropine intravenously
B. Administering small doses of
midazolam (Versed)
C. Encouraging additional fluids for
the next 24 hours
D. Ensuring the return of the gag
reflex before offering food or fluids
73. A nurse is assessing the respiratory
status of a male client who has suffered
a fractured rib. The nurse would expect
to note which of the following? A. Slow
deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially With inspiration
74 A female client with chest injury has
suffered flail chest. A nurse assesses
the client for which most distinctive sign
of flail chest
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation
75 A male client has been admitted
with chest trauma after a motor vehicle
accident and has undergone subsequent
intubation. A nurse checks the client
when the high-pressure alarm on the
ventilator sounds, and notes that the
client has an absence of breath sounds
in the right upper lobe of the lung. The
nurse immediately assesses for other
signs of: A Right pneumothorax
B Pulmonary embolism
C Displaced endotracheal tube
D Acute respiratory distress syndrome
76. A client has just been diagnosed
with type 1 diabetes mellitus. Which
comment by the client correlates best with
this disorder?
A. "I was thirsty all the time. I just
couldn't get enough to drink."
B. "It seemed like I had no appetite. I
had to make myself eat."
C. "I had a cough and cold that just
didn't seem to go away.'
D. "I noticed I had pain when I went to
the bathroom.
77. Which outcome would indicate
successful treatment of diabetes insipidus?
A. Fluid intake of less than 2,500 ml in 24
hours
B. Urine output of more than 200 ml/hr.
C. Blood pressure of 90/50
D. pulse rate of 126 beats/minute
79. A nurse administered NPH insulin
to a client with Diabetes mellitus at 7
am. At what time would the nurse
expect the client to be at greatest risk
for a hypoglycemic reaction? A. 10 am
B Noon
C. 4 pm
D. 10 pm
80. Which instruction should
included in the teaching plan for a client
requiring insulin?
A. Administer insulin
B. Administer insulin at a 45 degree
angle into a deltoid muscle
C. Shake the vial of insulin vigorously
before withdrawing the medication D.
Draw up clear insulin first when
mixing two types of insulin in one
syringe
81. A client with a serum glucose level
of 618 mg/dl is admitted to the facility.
He's awake and oriented; has hot, dry
skin; and has the following vital signs:
temperature 38.1 degrees Celsius, heart
rate of 116 beats/min and blood
pressure of 108/70 mmHg. Based on
these assessment findings, which
nursing diagnosis takes highest priority?
A. Deficient fluid volume related to
osmotic diuresis
B. Decreased cardiac output related to
osmotic diuresis
C. Imbalanced Nutrition: less than body
requirements related to insulin deficiency
D. Ineffective thermoregulation related to
dehydration
82. For the first 72 hours after
thyroidectomy surgery, a nurse would
assess a client for Chvostek's and
Trousseau's signs because they indicate:
A. Hypocalcemia
B. Hypercalcemia
C. Hypokalemia
D. Hyperkalemia
83. On a medical-surgical floor, the
nurse is caring for a cluster of clients who
have been diagnosed with diabetes
mellitus. Which client should the nurse
assess first?
A. An 80-year-old client with a blood
be glucose level of 350 mg/dl
B. A 20-year-old client with a blood
glucose level of 70 mg/dl
C. A 60-year-old client experiencing
nausea and vomiting
D. A 55-year-old client complaining
of chest pressure
84. The nurse is assigned to a 40-yr
old client who has a diagnosis of
chronic pancreatitis. The nurse reviews
the laboratory results, anticipating a
laboratory report that indicates a serum
amylase level of:
A. 45 units/L
B. 100 units/L
C. 300 units/L
D. 500 units/L
85. What laboratory finding is the
primary diagnostic indicator for
pancreatitis? A. Elevated blood urea
nitrogen (BUN)
B. Elevated serum lipase
C. Elevated aspartate aminotransferase
(AST)
D. Increased lactate dehydrogenase (LD)
86. A nurse is caring for client with
pheochromocytoma. The client asks for
a snack and something warm to drink.
The most appropriate choice for this 90. A nurse is providing discharge
client to meet nutritional needs would be instructions to a client who has
which of the following? A. Crackers with Cushing's syndrome. Which client
cheese and tea statement indicates that instructions
B. Graham crackers and warm milk related to dietary management are
C. Toast with peanut butter and cocoa understood?
D. Vanilla wafers and coffee with cream and A. "I can eat foods that have a lot of
Sugar potassium in them."
B. "I will need to limit the amount of
87. A nurse is performing an protein in my diet."
assessment on a client with C. "I am fortunate that I can eat all the
pheochromocytoma. Which of the salty foods I enjoy."
following assessment data would indicate D. "I am fortunate that I do not
a potential complication associated with need to follow any special diet."
this disorder? A. A coagulation time of 5
minutes 91. A client is taking NPH insulin daily
B. A blood urea nitrogen level of 20 mg/dl every morning. The nurse instructs the
C. A urinary output of 50 ml per hour D. A client that the most likely time for a
heart rate that is 90 beats/min and hypoglycemic reaction to occur is: A. 2 to
irregular 4 hours after administration
B. 4 to 12 hours after administration
88. A nurse is preparing to provide C. 16 to 18 hours after administration
instructions to a client with Addison's D. 18 to 24 hours after administration
disease regarding diet therapy. The
nurse knows that which of the following 92. A nurse provides dietary
diets most likely would be prescribed for instructions to a client with diabetes
this client? mellitus regarding the prescribed diabetic
A. High fat intake diet. Which statement, if made by the
B. Low protein intake Client, indicates a need for further
C. Normal sodium intake teaching?
D. Low carbohydrate intake A"I need to drink diet soft drinks
B."I will eat a balanced meal plan.
89. A nurse is interviewing a client with C."I need to purchase special diabetic
type 2 diabetes mellitus. Which foods— sure ni?
statement by the client indicates an D"I'll snack on fruits instead of cake
understanding of the treatment for this
disorder? A. "I take oral insulin instead of 93. A client received 20 units of NPH
shots" B. "By taking these medications, insulin subcutaneously at 8:00 am. The
I am able to eat more." nurse should assess the client for a
C. "When I become ill, I need to hypoglycemic reaction at: A 10:00 am
increase the number of pills I take." B 11:00 am
D. "The medications I'm taking help C 5:00 pm
release the insulin I already make. D. 11:00 pm
 94. The nurse is caring for a client
scheduled for a include in the teaching plan?
transsphenoidal hypophysectomy. The
preoperative teaching instructions should
include which most important statement?
A. *Your hair will need to be shaved." B.
Deep breathing and coughing will be
needed after surgery.'
C Brushing your teeth will not be
permitted for at least 2 weeks following
surgery.
D. You will receive spinal anesthesia.
95. A nurse caring for a client with
Addison's disease would expect to note
which of the following on assessment of
the client? A. Obesity
B. Edema
C. Hypotension D Hirsutism
96. A nurse is assessing a client with
a diagnosis of goiter. Which of the
following would the nurse expect to note
during the assessment of the client? A
Client complains of slow wound healing
B. Client complains of chronic fatigue
C An enlarged thyroid gland
D. The presence of heart damage
97. The nurse is caring for a client following
thyroidectomy. The nurse notes that
calcium gluconate is prescribed for the
client. The nurse determines that this
medication has been prescribed to: A.
Treat thyroid storm
B Prevent cardiac irritability
C. Stimulate release of parathyroid
hormone D. Treat hypocalcemia tetany
98. The client with type 1 diabetes
mellitus is to begin an exercise program
and the nurse is providing instructions
to the client regarding the program.
Which of the following does the nurse
A. Exercise is best performed during
peak times of insulin
B. Administer insulin after exercising
C. Take a blood glucose test before
exercising
D. Try to exercise prior to mealtime
99. The nurse is preparing to
administer an IV insulin injection. The
vial of regular insulin has been
refrigerated On inspection of the vial,
the nurse finds that the medication is
frozen. The nurse should: A Wait for the
insulin to thaw at room temperature
B. check the temperature settings of the
refrigerator
C Discard the insulin and obtain another
vial
D Rotate the vial between the hands
until the medication becomes liquid.
100. A nurse is assessing the learning
readiness 'of a client newly diagnosed
with diabetes mellitus. Which client
behavior indicates to the nurse that the
client is not ready to learn?
A. The client complains of fatigue
whenever the nurse plans a teaching
session
B. The client asks if the spouse can
attend the teaching session
C. The client asks for written
materials about diabetes mellitus before
class D. The client asks appropriate
questions about what will be taught
NP 4 III. Talking
IV. Valsalva maneuver V.
1. Select the main structures below that Vomiting
play a role with altering intracranial VI. Keeping the head of the bed
pressure: between 30- 35 degrees

I. Brain
II. Neurons
III. Cerebrospinal Fluid
IV. Blood
V. Periosteum
VI. Dura mater

A. I, II, III
B. I, III, IV
C. III, IV, VI
D. All mentioned

2. The Monro-Kellie hypothesis explains the

compensatory relationship among the
structures in the skull that play a role with
intracranial pressure. Which of the following
are NOT compensatory mechanisms
performed by the body to decrease
intracranial pressure naturally? Select all
that apply:
I. Shifting cerebrospinal fluid to other
areas of the brain and spinal cord II.
Vasodilation of cerebral vessels III.
Decreasing cerebrospinal fluid production
IV. Leaking proteins into the brain barrier

A. land Il
B. land IV
C. ll and IV
D. Ill and IV

3.A patient is being treated for increased

intracranial pressure. Which activities below
should the patient avoid performing? Select
all that apply;
I. Coughing
II. Sneezing
 A. I, II, IV,...........................................V
B. IlI IV. V C. I, IV. V.......................VI
D. II IV. V 4. A patient is experiencing hyperventilation and has a PaCO2 level of 52 The
patient has an ICP of 20 mmHg As the nurse you know that the PaCO2 level will? VI
D. Perform suctioning
A. cause vasoconstriction and decrease the
ICP 8.A patient has a ventriculostomy. Which
B. promote diuresis and decrease the ICP finding would you immediately report to the
C. cause vasodilation and increase the doctor?
ICP A. Temperature 98 4 'F
D. cause vasodilation and decrease the B. CPP 70 mmHg
ICP C. ICP 24 mmHg
D. PaC02 35
5. You're providing education to a
group of nursing students about ICP. You 9. External ventricular drains monitor IP and
explain that when cerebral perfusion are inserted where? A. Subarachnoid
pressure falls too low the brain is not space
properly perfused and brain tissue dies. A B. Lateral Ventricle
student asks, "What is a normal cerebral C. Epidural space
perfusion pressure level? Your response D. Right Ventricle
is:
A. 5-15 mmHq 10. Which of the following is contraindicated
B. 60-100 mmHg in a patient with increased ICP? A. Lumbar
C. 30-45 mmHg D. 160 mmHg puncture B. Midline position of the head C,
Hyperosmotis-diuretics.
6. Which patient below is at MOST D. Barbiturate medications
risk for increased intracranial pressure? A
patient who is experiencing severe 11. You’re collecting vital signs on a
hypotension. patient with ICP. The patient has a
B. A patient who is admitted with a Glascoma scale rating 4. How will you
traumatic brain injury. assess the patient's temperature? A.
C. A patient who recently experienced a Rectal
myocardial infarction B. Oral
D. A patient post op from eye surgery C. Axillary
7. A patient with increased ICP has the D. Auricle
following vital signs: blood pressure 99/60. 12. A patient who experienced a cerebral
HR 65, Temperature 101.6 'F, respirations hemorrhage is at risk for developing
14, oxygen saturation of 95%. IP reading is increased Which sign and symptom below
21 mmHg Based on these findings you is the EARLIEST indicator the patient is
would? having this complication? A. Bradycardia
A. Administered PR dose of a B. Decerebrate posturing
vasoresso! B. Administer 2 L Of oxvgen C. Restlessness
C. Remove extra blankets and give the D. Unequal pupil size
patient a cool patch
 13. Select all the signs and symptoms that
occur with increased ICP
I. Decorticate posturing
II. Tachycardia
III. Decrease in pulse pressure
IV. Cheyne-stokes
V. Hemiplegia
VI. Decerebrate posturing
A. I, II, III, IV
B. I, IV. V. VI
C. III, IV, V, VI
D. All mentioned
14. You're maintaining an external
ventricular drain The ICP readings should
be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg
15. Which patient below with ICP is
experiencing Cushing's Triad? A patient
with the following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60. HR 80. RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12
16. The patient has a blood pressure of
130/88 and ICP reading of 12. What is the
patient's cerebral pension pressure, and
now do you interpret this as the nurse?
A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHa, normal
17. Per question 16, the patient's blood
pressure is 130/88. What is the patient's
mean arterial pressure (MAP)?
A. 42
B. 74
C. 102
D. 88
18. During the assessment of a patient with
increased ICP, you note that the patient's
arms are extended straight out and toes
pointed downward. You will document this
as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
D. Catatonia
19. While positioning a patient in bed with
increased ICP, it important to avoid? A.
Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
20. During the eye assessment of a patient
with increased ICP, you need to assess tha
oculocephalic reflex. If the patient has brain
stem damage what response will you find?
A. The eyes will move in the same direction
as the head is moved side to side B. The
eyes will move in the opposite direction as
the head is moved side to side C. The eves
will roll back as the head is moved side to
side.
D. The eyes will be in a fixed midline
position as the head is moved side to side.
21. All the following causes of Spinal Cord
Injuries are non-traumatic in nature, which is
not included?
A. Rheumatoid Arthritis and Ankylosing
B. Spondylitis
C. Vascular problems
D. Electric shock
22. Mr. Yoshihiro Sato, an Olympic
swimmer, suffered from a diving accident
and had respiratory arrest before being
transferred to the hospital. The nurse
seeing the scene opens the patient's
airway to provide rescue breathing using
which maneuver?
A. Head tilt
B. Jaw thrust
C. Chin lift
D. Logroll technique
23. Injuries involving the spinal cord in
the thoracic level will lead to a paralysis
confined to the lower limbs, a condition
known as A.Aletradlecia
B.Hemiplegia
C.Quadriplegia
D.Paraplegia
24. Mr. Blake is confirmed to be having
a spinal cord injury at the sacral level (S3).
The nurse includes in the plan of care of
Mr. Blake, which interventions?
A Insertion of a foley catheter B.Monitoring
the patient while being hooked to a
mechanical ventilator
C. Exercises to prevent atrophy of the
paralyzed upper and lower extremities
D.Coping strategies for sensory and motor
deficits on the left/right half of the body.
E All the above
25. Which of the ff. is given to a patient
with spinal cord injury, primarily to address
hypotension?
A.Calcium channel blocker
B.Dextran
C.Methylprednisolone Sodium Succinate
D.Mannitol
26. A nurse is reviewing the health care
record of a client with a new diagnosis of
rheumatoid arthritis (RA). The nurse
understands that which of the following is
an early clinical manifestation of RA? A.
Complaints of fatigue
B. Increased energy level
C. Increased appetite
D. Weight gain
27. A nurse is caring for a client with a
diagnosis of gout. Which of the following
laboratory values would the nurse expect to
note in the client
A Calcium level of 9.0 mg/dL
B. Uric acid level of 8.6 mg/dL
C. Potassium level of 4.1 mg/dL
D. Phosphorus level 3.1 mg/dL
28. A nurse is caring for a client with
osteoarthritis . The nurse performs an
assessment, knowing that which of
the following is a clinical
manifestation associated with the
disorder? A. Morning stiffness
B. A decreased sedimentation rate
C. Joint pain that diminishes after rest D.
Elevated antinuclear antibody levels
29. The client has had surgery to repair a
fractured hip. The nurse obtains which of
the following most important items from the
unit storage area to use when repositioning
the client from side to side in bed?
A. Abductor splint
B. Adductor splint
C. Bed pillow
D. Overhead trapeze
30. The nurse has developed a plan of care
for a client who is in traction and documents
a nursing diagnosis of self-care deficit. The
nurse evaluates the plan of care and
determines which of the following
observations indicates a successful
outcome?
A. The client allows the nurse the nurse to
complete the care daily
B. The client allows the family to assist in
the care
C. The client refuses care
D. The client assists in self-care as much
as possible
31. A home care nurse is visiting a client
who is in a body cast. The nurse is
performing an assessment and Is assessing
the psychosocial adjustment of the client to
the cast. The nurse would most
appropriately assess the
A. Type of transportation available for
follow-up care
B. Ability to perform activities of daily living
C. Need for sensory stimulation
D. Amount of home care support available
32. A community health nurse is providing
an educational session for community
members regarding dietary measures that
will assist in reducing the risk of
osteoporosis. The nurse instructs the
community members to increase dietary
intake of which food known to be helpful
in minimizing this risk?
A. Yogurt
B. Turkey
C. Spaghetti
D. Shellfish
33. A nurse is teaching a client with a right
arm cast how to prevent stiff or frozen
shoulder. The nurse should instruct the
client to:
A Keep a sling on the arm always
B.Lift the shoulder of the casted arm
over the head-periodically throughout
the day
C. Avoid range-of-mation exercises
D. Wear the sling at nighttime
34. A nurse is performing neurovascular
assessment on a client with a cast on the
left lower leg. The nurse notes the
presence of edema in the foot below the
cast. The nurse would interpret that this
finding indicates:
A. Impaired arterial circulation
B. The presence of an infection
C. Impaired venous return
D. Arterial insufficiency
35. A client is complaining of knee pain.
The knee is swollen, reddened and warm to
touch. The nurse interprets that the client's
signs and symptoms are not compatible
with:
A. Inflammation
B. Degenerative disease
C. Infection
D. Recent injury
36. A nurse witnesses a client sustain a fall
and suspects that the right leg may be
broken. The nurse takes which priority
action?
A. Take a set of vital signs
B. Call the radiology department C.
Reassure the client that everything will
be
D. Immobilize the right leg before moving
the client.
37. A nurse in the hospital emergency
department is caring for a client with a
fractured arm and is preparing the client for
a reduction of the fracture that will be done
in the casting room. Which of the following
is unnecessary?
A. Explanation of the procedure to the client
B. Administration of an analgesIc
C. Anesthesia consent
D. Consent for the procedure
38. A nurse has suggested specific leg
exercises for a client immobilized in right
skeletal lower leg traction. The nurse
determines that the client needs further
instruction of the nurse observes the client:
A. Pulling up using the trapeze
 B. Flexing and extending the feet C.
Performing active range of motion to the
right ankle and knee
D. Doing quadriceps-setting and gluteal
setting exercises
39. A client has a slight weakness in the
right leg. Based on this assessment finding,
the nurse determines that the client would
benefit most from the use of A. walker
B. A wooden crutch
C. A Lofstrand crutch
D. A straight leg cranes
40. A client who has experienced a brain
attack (stroke) has partial hemiplegia of the
left leg. The straight leg cane formerly used
by the client is not quite sufficient now. The
nurse interprets that the client could benefit
from the somewhat greater support and
stability provided by a
A. Quad cane
B. Wooden crutch
C. Loistrand crutch
D. Wheelchair
41. A client who is learning to use a cane is
afraid that they will slip with ambulation,
causing a fall. The nurse provides the client
with the greatest reassurance by stating
that.
A. Canes prevent falls; they do not cause
ther
B. The cane has a flared tip with
concentric rings to give stability C. The
physical therapist will determine if the
cane is inadequate
D. The cane would help to break a fall,
even if you do slip
42. A nurse in the hospital emergency
department is assessing a client with an
open leg fracture. The nurse inquires
about the date of the client's last A.
Physical examination
B. Chest radiograph
C. Tetanus vaccine
D. Tuberculin test
43. A client has just been admitted to the
hospital with a fractured femur and pelvic
fractures. The nurse plans to carefully
monitor the client for which of the
following signs and symptoms? A.
Tachycardia, hypotension
B. Bradycardia, hypertension
C. Fever, bradycardia
D. Fever, hypertension
44. A client is complaining of pain
underneath a cast in a bony prominence.
The nurse interprets that this client may
need:
A. To have the cast replaced with an air
splint
B. To have extra padding put over this area
of the cast
C. To have the cast bivalve
D. To have a window cut in the cast
45. A test for the presence of rheumatoid
factor is performed in a client with a
diagnosis of rheumatoid arthritis. The nurse
understands that this test assesses for the
presence of:
A. Unusual antibodies of the IgG and IgM
type B. Antigens
of IgA
C. Inflammation
D. Infection in the body
46. You are initiating a nursing care plan
for a patient with osteoporosis. These
nursing interventions apply to the nursing
diagnosis Risk for Falls. Which intervention
should you delegate to the nursing
assistant? A. Identify environmental factors
that increase risk for falls.
B. Monitor gait, balance, and fatigue
level with ambulation.
C. Collaborate with physical therapy to
provide patient with walker
D. Assist the patient with ambulation to
bathroom and in halls.
47. You are preparing to teach a newly
diagnosed patient with osteoporosis about
strategies to prevent falls. Which of these
points will you be sure to include? (Choose
all that apply.)
A. Wear a hip protector when
ambulating.-
B. Remove throw rugs and other
obstacles at home-
C. Exercise will help build your
strength- D. You should expect a few
bumps and bruises when you go home E.
When you are tired, you should rest.-
48. You discover these assessment
findings when admitting a patient with
Paget's disease. Which finding indicates
that the physician should be notified?
A. A. The patient has bowing of both legs
and the k nees are asymmetricasymmetric
B. The base of the patient's skull is
Invaginated (platypasia).
C. The patient is only 5 feet tall and
weighs 120 pounds.
D. D. The patient's skull is soft, thick,
and larger than normal
49. As charge nurse you observe the
LPN/LVN providing these interventions for
the patient with Paget's disease. Which
action requires that you intervene?
A. Administers 600 mg of ibuprofen to
the patient
B. Encourages the patient to perform
PT recommended exercises
C. Applies ice and gentle massage to
the patient's lower extremities
D. Reminds the patient to drink milk
and eat cottage cheese
50. As charge nurse you are making
assignments for the day shift. Which patient
would you assign to the nurse who has
been pulled from the post-anesthesia care
unit (PACU) for the day?
A. A 35-year-old patient with
osteomyelitis who needs teaching prior to
hyperbaric oxygen therapy
B. A 62-year-old patient with
osteomalacia who is being discharged to a
long-term care
facility
C. A 68-year-Old patient with
osteoporosis and a new orthotic device
whose knowledge of use of this device
must be assessed. D. A 72-year-old patient
with Paget's disease who has just returned
from surgery for total knee replacement
51. A patient is admitted to the hospital
after vomiting bright red blood and is
diagnosed with a bleeding duodenal ulcer.
The patient develops a sudden, sharp pain
in the midepigastric region along with a
rigid, boardlike abdomen. These clinical
manitestations most likely indicate which of
the following?
A. An intestinal obstruction has developed.
B. The ulcer has perforated.
C. Additional ulcers have developed
D. The esophagus has become inflamed
52. The patient asks the nurse what causes
a Peptic Ulcer to develop. The nurse
responds that recent research indicates that
many peptic ulcers are the result of which of
the following?
A. Helicobacter pylori infection
B. Diets high in fat
C. Work-related stress.
D. A genetic defect in the gastric mucosa.
53. The nurse is preparing to teach a
patient with a Peptic Ulcer about the diet
that should be followed by discharge. The
nurse should explain that the diet will most
likely consist of the following.
A. Any foods that are tolerated.
B. Large amounts of milk.
C. Bland foods.
D. High-protein foods.
54. A patient is to take one daily dose of
ranitidine (Zantac) at home to treat her
peptic ulcer. The nurse knows that the
patient understands proper drug
administration of ranitidine when she says
that she will take the drug at which of the
following times?
A. When pain occurs.
B. Before meals.
C. With meals.
D. At Bedtime
55. Which of the following would be an
expected outcome for a patient with Peptic
Ulcer disease?
A. The patient will explain the rationale
for eliminating alcohol from the diet .
B. The patient will verbalize the
importance of monitoring hemoglobin and
hematocrit every 3 months.
C. The patient will demonstrate
appropriate use of analgesics to control
pain.
D. The patient will eliminate contact
sports from his or her lifestyle
56. A patient with suspected gastric cancer
undergoes an endoscopy of the stomach.
Which of the following assessments made
after the procedure would indicate the
development of a potential complication? A.
The patient complains of a sore throat. B.
The patient demonstrates a lack of appetite
C. The patient displays signs of sedation.
D. The patient experiences a sudden
increase in temperature
57. After a subtotal Gastrectomy, the
nurse should anticipate that NGT drainage
will be what color for about 12 to 24 hours
after surgery?
A. Bright red.
B. Cloudy white.
C. Dark brown.
D. Bile green.
58. The nurse understands that the best
position for the patient who has undergone
a Gastrectomy is: A. Supine.
B. Prone.
C. Low Fowlers
D. Right or left Sim's.
59. To reduce the risk of dumping
syndrome, the nurse should teach the
patient which of the following interventions?
A. Decrease the carbohydrate content of
meals.
B. Avoid milk and other dairy products.
C. Drink liquids with meals, avoiding
caffeine
D. Sit upright for 30 minutes after meals.
60. Which of the following symptoms would
be indicative of the Dumping Syndrome?
A. Diaphoresis.
B. Vomiting.
C. Hunger D. Heartburn.
61. After surgery for gastric cancer, a
patient is scheduled to undergo radiation
therapy. It will be most important for the
nurse to include information about which of
the following in the patient's teaching plan?
A. Nutritional intake B. Exercise and
activity levels.
C. Management of alopecia.
D. Access to community resources.
Situation: A patient who has been
diagnosed with Gastroesophageal reflux
disease (GERD) complains of heartburn.
62. To decrease the heartburn, the
nurse should instruct the patient to
eliminate which of the following items from
the diet? A. Hot chocolate.
A. Air-popped popcorn.
B. Raw vegetables
C. Lean beef
63. The patient with GERD complains of
a chronic cough. The nurse understands
that in a patient with GERD this symptom
may be indicative of which of the following
conditions.
A. Aspiration of gastric contents .
B. Development of laryngeal cancer.
C. Esophageal scar tissue formation.
D. Irritation of the esophagus.
64. The patient attends two sessions
with the dietician to learn about diet
modifications to minimize
Gastroesophageal Reflux. The teaching
would be considered successful if the
patient says that she will decrease her
intake of which of the following foods?
A. Fats B. High-sodium foods
C. Carbohydrates.
D. High-calcium foods.
65. Which position would be ideal for the
patient in the early postoperative period
after a Hemorrhoidectomy? A. Supine.
B. Side-lying.
C. Trendelenburg
D. High-Fowler's.
66. When the patient's common bile duct
is obstructed, the nurse should evaluate
the patient for signs of which of the
following complications?
A. Circulatory overload.--?
B. Urinary tract infection.
C. Prolonged bleeding time.
D. Respiratory distress.**
67. How much bile would the nurse
expect the T- tube to drain during the first
24 hours after a Choledocholithotomy? A.
300 to 500 mL.
B. 550 to 700 mL.
C. 50 to 100 mL.
D. 150 to 250 mL
68. After a Cholecystectomy it is
recommended that the patient follow a low-
fat diet at home. Which of the following
foods would be most appropriate to include
in a low-fat diet?
A. Roast beef.
B. Cheese omelet
C. Peanut butter
D. Ham salad sandwich
69. Which of the following discharge
instructions would be appropriate for a
patient who has had a laparoscopic
Cholecystectomy?
A. Change the dressing daily until the
incision nedis
( Leave dressings in place until you
see the surgeon at the postoperative
visit. Sa quizlet)
B. Avoid showering for 48 hours after
surgery.
C. Use acetaminophen (Tylenol) to control
any fever
D. Return to work within 1 week.
70. Celso is admitted to the hospital
with acute pancreatitis. The nurse
taking a history should question the
client about which of these risks for
developing pancreatitis ? A.
inflammatory bowel disease
D. alcoholism
B. diabetes mellitus
D. high-fiber diet
71. Which of the following factors should be
the focus of nursing management in a client
with Acute Pancreatitis? A. Fluid and
electrolyte balance.-
B. Management of hypoglycemia
C. Pain control.
D.Dietary management.
72. In alcohol-related pancreatitis, which of
the following interventions is the best way to
reduce the exacerbation of pain? A. Eating
a low-fat diet.
B. Abstaining from alcohol.
C. Lying supine.
D. Taking aspirin.
73. Which of the following findings would
strongly indicate the possibility of Cirrhosis?
A. Pruritus B.
Peripheral edema.
C. Hepatomegaly.
D. Dry skin.
74. The nurse is aware that the
symptoms of Portal Hypertension in
clients with liver cirrhosis are chiefly the
result of. A. Infection of the liver
parenchyma
B. Fatty degeneration of Kupffer cell
C. Obstruction of the portal circulation D.
Obstruction of the cystic and hepatic
ducts
75. Which goal for the patient's care should
take priority during the first day of
hospitalization for an exacerbation of
Ulcerative Colitis?
A. Maintaining adequate nutrition.
B. Managing diarrhea.
C. Promoting self-care and independence.
D. Promoting rest and comfort.
Situation: Pedro consulted a urologist
because of his chronic renal problem. The
physician advised him to undergo peritoneal
dialysis.
76. Which of the following assessments
would be most appropriate for the nurse to
make while the dialysis solution is
dwelling within the patient's abdomen?
A. Check capillary refill time
B. Assess for urticaria.
C. Monitor electrolyte status D.
Observe respiratory status.
77. The dialysis solution is warmed before
use in peritoneal dialysis primarily to:
A. force potassium back into the cells
B. promote abdominal muscle
relaxation.
C. add extra warmth to the body
D. encourage the removal of serum urea
78. During dialysis, the nurse observes that
the flow of dialysate stops before all the
solution has drained out. The nurse should:
A. Reposition the peritoneal catheter
B. Have the patient sit in a chair.
C. Have the patient walk.
D. Turn the patient from side to side.
79. Which of the following nursing
interventions should be included in the
patient's care plan during dialysis therapy?
A. Keep the patient NPO.
B. Monitor patient's blood pressure.
C. Limit the patient's visitors.
D. Pad the side rails of the bed.
80. What is the most potentially
dangerous complication of peritoneal
dialysis? A. Muscle cramps.
B. Abdominal pain.
C. Gastrointestinal bleeding.
D. Peritonitis
81. After completion of peritoneal
dialysis, the nurse would expect the
patient to exhibit which of the following
characteristics? A. Weight loss.
B. Hypertension.
C. Hematuria.
D. Increased urine output.
Situation: Cecil a 38-year married woman,
seeks consultation for painful urination,
urgency in voiding and fever for 3 days.
82. Which of the following symptoms
would most likely indicate Pyelonephritis?
A. Costovertebral angle (CVA) tenderness
B Nausea and vomiting
C. Ascites
D. Polyuria.
83. The nurse is aware that one of the
following laboratory values will support a
diagnosis of Pyelonephritis.
A. Myoglobinuria
B. Pyuria
C. Ketonuria
D. Low white blood cell (WBC) count
84. The patient with acute Pyelonephritis
wants to know the possibility of developing
chronic Pyelonephritis. The nurse's
response is based on knowledge that which
of the following disorders most commonly
leads to chronic Pyelonephritis?
A. Acute renal failure
B. Recurrent UTI C. Acute
pyelonephritis.
D. Glomerulonephritis.
Situation: Gina 24-year-old, patient who is
newlywed comes to an ambulatory clinic in
moderate distress with a diagnosis of acute
cystitis,
85. Which of the following symptoms
would the nurse most likely expect the
patient to report during the assessment?
A. Hematuria
B. Frequency and burning on urination
C. Flank pain and nausea
D. Fever and chills
86. The patient asks the nurse, "How did
I get this urinary tract infection?" The nurse
should explain that in most instances,
cystitis is caused
A. Congenital strictures in the urethra.
B. An infection elsewhere in the body
C. Urine stasis in the urinary bladder D. An
ascending infection from the urethra.
87. The patient is afraid to discuss her
diagnosis of Cystitis with her husband.
Which would be the nurse's best approach?
A. Spend time with the patient addressing
her concerns and then stay with her while
she talks with her husband.
B. Talk first with the husband alone
and then with both of them together to
share the husband's reactions.
C. Insist that the patient talk with her
husband because good communication is
necessary for a successful marriage D.
Arrange a meeting with the patient, her
husband the doctor and the nurse
88. The nurse teaches a patient some
method to relieve her discomfort until the
antibiotic takes effect. Which of the following
responses by the patient would indicate that
she understands the Nurse's instructions?
A. "I will place ice packs on my perineum."
B. I will drink a cup of warm tea every
hour
C. *I will take hot tub baths." D. I will
void every 5 to 6 hours.
89. Which of the following statements by
the patient would indicate that she is at high
risk for recurrence of Cystitis? A. "I drink a
lot of water during the day
B. "I take a tub bath every evening C. "I
wipe from front to back after voiding.
D. "I can usually go 8 to 10 hours without
needing to empty my bladder.
90. A client who has been treated for
chronic renal failure (CRF) is ready for
discharge. The nurse should reinforce which
dietary instruction? A. "Be sure to eat meat
at every meal" B. "Monitor your fruit intake,
and eat plenty of bananas.
C. "Increase your carbohydrate intake
D. "Drink plenty of fluids, and use a salt
substitute."
91. A client with renal failure is undergoing
continuous ambulatory peritoneal dialysis.
Which nursing diagnosis is most appropriate
for this client?
A. Altered urinary elimination
B. Toileting self-care deficit
C. Risk for infection
D. Activity intolerance
92. The client underwent a transurethral
resection of the prostate gland 24 hours ago
and is on continuous bladder irrigation.
Which of the following nursing interventions
is appropriate?
A. Tell the client to try to urinate around
the catheter to remove blood clots B.
Restrict fluids to prevent the client's
bladder from becoming distended. C.
Prepare to remove the catheter.
D. Use aseptic technique when irrigating
the catheter
93. The nurse is inserting a urinary catheter
into a client who is extremely anxious about
the procedure. The nurse can facilitate the
insertion by asking the client to:
A. initiate a stream of urine
B. breathe deeply
C. Turn to the side
D. hold the labia or shaft of penis.
94. Which steps should the nurse follow to
insert a straight urinary catheter?
A. Create a sterile field, drape client, clean
meatus, and insert catheter only 6 B. Put
on gloves, prepare equipment, create a
sterile field, expose urinary meatus, and
insert catheter 6"
C. Prepare client and equipment,
Create à sterile field, put on gloves, clean
urinary meatus, and insert catheter until
urine flows.
D. Prepare client and equipment, sterile
field test catheter balloon clean meals, and
insert catheter until unne flows
95. Which of the following is an appropriate
nursing diagnosis for a client with renal
calculi?
A.Ineffective tissue perfusion
B. Functional urinary incontinence
C.Risk for infection
D. Decreased cardiac output
96. Which clinical manifestation would
lead the nurse to suspect that a client Is
experiencing hypermagnesemia? A.
Muscle pain and acute rhabdomyolysis
B. Hot, flushed skin and diaphoresis
C.Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth
97. Joshua is receiving furosemide and
Digoxin, which laboratory data would be the
most important to assess in planning the
care for the client? A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level
 98. Mr. Salcedo has the following arterial
blood gas (ABG) values: pH of 7.34, partial
pressure of arterial oxygen of 80 mm Hg,
partial pressure of arterial carbon dioxide of
49 mm Hg, and a bicarbonate level of 24
mEq/L. Based on these results, which
intervention should the nurse implement?
A. Instructing the client to breathe slowly
into a paper bag B. Administering low-flow
oxygen C. Encouraging the client to
cough and deep breathe
D. Nothing, because these ABG values are
within normal limits.
99. A client is diagnosed with metabolic
acidosis, which would the nurse expect the
health care provider to order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator

100. Lee Angela's lab test just revealed

that her chloride level is 96 mEq/L. As a
nurse, you would interpret this serum
chloride level as: A. high
B. low
C. within normal range
D. high normal
NP 5
1. A patient who has a hemorrhage in the
vitreous cavity of the eye, the nurse
knows that blood is accumulating A. in
the aqueous humor.
B. between the lens and the retina
C. between the cornea and the lens.
D. in the space between the iris and the
lens.
2. The nurse instructs a family member
how to guide a visually impaired person
when ambulating by:
A. holding the visually impaired person
by his or her nondominant arm and walking
side by side.
B. holding the nondominant hand,
wrapping the arm around his or her waist,
and walking side by side.
C. allowing the visually impaired person
to hold the helper's arm, with the helper
slightly ahead.
D. allowing the visually impaired person
to hold the shoulder of the helper and walk
slightly behind the helper.
3. The patient tells you that he has to hold
his paper farther and farther away from his
face to read it. It has become a joke in his
family about how far away he needs to hold
reading material. You tell the patient:
A. "You have myopia. Glasses will help
you read.”
B. You may have astigmatism, and
your eyes will get used to the problem.
C. "You have presbyopia, which is a
normal age-related change. Reading
glasses will help you.
D. "You may have an eye infection that
is affecting your vision. You will need an
antibiotic ointment to instill into your eyes
4. A client with impaired vision is admitted
to the hospital. The following interventions
are appropriate to meet the client's needs
EXCEPT
A. Identify yourself by name B.
Stay in the client's field of vision.
C. Explain the sounds in the environment
D. Decrease background noise before
speaking.
5. The nurse should always assess the
patient with an ophthalmic problem for
A. Visual acuity.
B. pupillary reactions
C. intraocular pressure
D. confrontation visual fields
6. Increased intraocular pressure may
occur as a result of
A. edema of the corneal stroma
B. dilation of the retinal arterioles.
C. blockage of the lacrimal canals and
ducts.
D. increased production of aqueous humor
by the ciliary body.
7. A patient is diagnosed with close-angle
glaucoma. The nurse prepares the patient
on what diagnostic procedure to visualize
the anterior chamber angle?
A. Ophthalmoscopy
B. Gonioscopy
C. Retinoscopy
D. Bio microscopy
8. The nurse should specifically question
patients using eyedrops to treat glaucoma
about
A. use of corrective lenses.
B. their usual sleep patterns
C. a history of heart or lung disease.
D. sensitivity to opioids or depressants.
 9. When assessing the visual fields in
acute glaucoma, the nurse would expect to
find a: A. clear cornea.
B. marked blurring of vision.
C. constricted pupil.
D. watery ocular discharge
10. A client is diagnosed with acute angle
glaucoma and is placed on oral osmotic
diuretic therapy . Which of the following will
the Nurse include in his health teachings
during acute phase of his illness?
A. Measurement of intake and output.
B. Using metal eye patch to protect the eye.
C. Otic drop administration.
D. Keeping his belonging well organized at
all times. -?
11. When irrigating a patient's ear, the
nurse will: straighten the ear canal and
irrigate with a large-tipped bulb syringe.
A. Straighten the ear canal and irrigate with
a large-tipped bulb syringe
B. direct the solution to the middle of the
canal to avoid damaging the ear.
C. use a body temperature solution and
have the patient hold a basin under the
ear while directing the solution toward
the top of the canal.
D. repeat the irrigation with hotter water.
12. Nurse Sylvia was approached by a
teenager crying in pain because of an ant
that has entered her ears. What should be
Nurse Sylvia's action?
A. Irrigate the ear using a cerumenolytic
agent.
B. Use a moist cotton bud to remove the
insect.
C. Instill a small amount of mineral oil
D. Blow a smoke towards the patient's ear,
Situation: Mr. Timothy Harris, a 78-year-old
patient, subjected himself to medical
treatment because of severely diminished
hearing acuity. His ears were inspected by
an Otolaryngologist and it was found Out
that both of his auditory canals were
obstructed by an impacted cerumen.
13. Nurse Savannah is knowledgeable
that Mr. Harris' condition is most
commonly caused by: A. an acute ear
infection.
B. overactive ceruminous glands
C. poor hygiene.
D. Concurrent dermatosis
14. Initial intervention for an impacted
cerumen involves irrigation of a
cerumenolytic agent to the involved ear.
Nurse Savannah prepares which solution to
most effectively soften the impacted
cerumen? A. 0.9% NaCI solution
B. Gentamycin drops
C. Atropine Sulfate drops
D. Peroxide in Glyceryl
15. When the nurse reads in the patient's
history that the patient has experienced
otalgia , the nurse knows that the patient
has:
A. difficulty hearing.
B. a buildup of cerumen.
C. ear pain.
D. ringing in ears.
16. Nursing instructions for a patient
suffering from external otitis should include
the
A. Application of heat to the auricle.
B. Avoidance of swimming.
C. Ingestion of over-the-counter analgesics,
such as aspirin.
D. All of the above.
17. The nurse points out to the client that of
the activities in which he is regularly
involved, the one that contributes to
accumulation of cerumen in the external ear
is:
A. swimming in a chlorinated pool daily.
B. drinking 1500 mL. of fluid a day.
C. trimming hair from the ears every week
D. washing the ears with a washcloth
every day.
Situation: Otitis media is currently
considered as an important public health
problem which may produce long-term
effects on language, auditory and
cognitive development.
18. Which classification of otitis media
according to duration is APPROPRIATELY
described?
A Acute Otitis Media = resolves within 6
months
B. Chronic Otitis Media = occurs longer
than
12 months
C. Subacute Otitis Media = occurs for 6 to
12 months
D. All of the above
E. None of the above
19. Identification of risk factors in key to
prevention of Otitis Media. The nurse lists
down the risk factors and includes which of
the following? (Select all that apply)
A.Chronic upper respiratory infection
B.Congenital abnormalities (Cleft Palate
Down Syndrome)
C.Daily intake of aspirin
D. Exposure to secondhand smoke
20. Suppurative Otitis media can be due
to the following BUT ONE A. May follow
a viral disease.
B. Barotrauma.
C. Tympanic membrane perforation
D. Follows a forceful nose blowing
Situation: Mr. Tonio a 49-year-old, a jolly
person works at the Commercial bank for
13 years had been informed for some
changes in is work load.m Three
months after he was observed of
unbecoming behavior. He was
diagnosed with Bipolar I disorder and
experiencing a Manic episode is newly
admitted to the inpatient psychiatric unit.
21. Which nursing diagnosis is a priority at
this time?
A. Risk for violence: other-directed R/T poor
impulse control
B. Altered though process RT hallucinations
C. Social isolation R/T manic excitement D.
Low self-esteem R/T guilt about
promiscuity
22. In the mental hospital Mr. Tonio is
yelling at another peer in the milieu. Which
nursing intervention takes priority?
A. calmly redirect and remove the client
from the milieu
B. administer prescribed PRN
intramuscular injection for agitation C.
notify the client to lower voice D. obtain an
order for seclusion to help decrease
external stimuli
23. Another client diagnosed with bipolar Il
disorder has a nursing djagnosis of
impaired social interactions R/T
egocentrism. Which short-term outcome is
an appropriate expectation for this client
problem?
A. the client will have an appropriate
one-on- one interaction with a peer by
day 4
B. the client will exchange personal
information with peers at lunchtime C.
the client will verbalize the desire to
interact with peers by day 2 D. the client
will initiate an appropriate social
relationship with a peer
24. An adult client 52 years old, diagnosed
with major depressive disorder is being
considered for electroconvulsive therapy
(ECT). Which client teaching should the
nurse prioritize?
A. empathize with the client about fears
regarding ECT
B. monitor for any cardiac alterations to
avoid possible negative outcomes C.
discuss the client and family expected
short-term memory loss
D. inform the client that injury related to
induced seizure commonly occurs
25. A nursing instructor is teaching about
the cause of mood disorders. Which
statement by a nursing student best
indicates an understanding of the etiology of
mood disorders?
A. When clients experience loss, they
learn that it is inevitable and become
hopeless and helpless.
B. "There are alterations in the
neurochemicals, such as serotonin, which
cause the client's symptoms C. "Evidence
continues to support multiple causations
related to an individual's susceptibility to
mood symptoms.'
D. "There is a genetic component affecting
the development of mood disorder."
Situation: Paulo 9 years old is diagnosed
with an autistic disorder makes no eye
contact; is unresponsive to staff members
and continuously twists, spins, and head
bangs,
26. What is meant by the "fittingness" of a
research study?
A. Truth of findings as judged by the
participants
B. The appropriateness of the interview
questions posed
C. Faithfulness to everyday reality of the
participants
D. The adequacy of the coding system used
27. What is a characteristic of an intrinsic
case study?
A. It yields a better understanding of each
case.
B. It provides a foundation to challenge a
generalization.
C. It does not include quantitative data.
D. It can scrutinize only uncomplicated
Phenomena.
28. Which of the following is most
accurate regarding the grounded-theory
method? A. Data are collected using an
etic perspective.
B. It is a process of constructing human
experience.
C. Secondary sources are sometires used
D. It is an inductive approach.
29. Nursing Research can be classified
according to the time frame the research
study has been made As a nurse, you know
that the study entitled *Knowledge and
practice of Staff Nurses in preventing
needle prick injuries in a private hospital in
Manila is classified as
A. Basic Research
B. Historical Research
C. Descriptive Research
D. Experimental Research
30. Nursing Research has a lot of
purposes, Which of the following category
do the study about sociodemographic
profile of nursing students and their risk for
depression belong? A. Prescription
B. Exploration
C. Prediction and control
D. Explanation
31. In an experimental research, as a nurse
there must be an essential aclivily wherein
the participants of the study will be able to
understand the whole experimental design.
This term is called:
A. Desensitization
B. Experimental Proper
C. Research Proper
D. Debriefing
32. Ethics in Nursing Research has always
been an issue when it comes to the identity
of the respondents. When the topics of
research are very sensitive, which of the
following rights of individual participants
must be ensured when the researcher
cannot link the information given by the
respondent from the source of the
information? A. Confidentiality
B. Anonymity
C. Virility
D. Volunteerism
33. In starting a focused group discussion,
Nurse Dina wants to stress out the
confidentiality of the topics that they will be
discussing. Which of the following
instruction convey confidentiality?
A. "This discussion should not only be
confined within this group of people. Any
information discussed should be told
publicly."
B. "This discussion should only be
confined within this group of people. Any
information discussed should not be told
publicly."
C "This discussion should not be confined
within this group of people. Any information
discussed should not be told publicly.
D. "This discussion should only be confined
within this group of people. Any information
discussed should be told publicly."
34. Based on the research title which of the
following will be the general objective?
A. This study aims to determine the
level of knowledge and practice of
prevention of needle prick injuries of Staff
Nurses in a certain private hospital.
B. This study aims to determine if there
is a significant relationship between levels
of knowledge regarding prevention of
needle prick injuries and sociodemographic
of Staff nurses in a certain private hospital.
C. The study aims to determine the
levels of knowledge regarding prevention
of needle prick injuries of staff nurses in a
certain private hospital
D. This study aims to determine the
isociodemographic of staff nurses in a
certain private hospital.
35 All of these are specific objectives
except A. This study is for nursing
researchers in the future.
B. This study aims to determine if there is a
significant relationship between levels of
knowledge regarding prevention of needle
prick injunes and sociodemographic of Staff
Nurses in a certain private hospital.
C.This study aims to determine the levels
of knowledge regarding prevention of
needle prick injuries of Staff Nurses in a
certain private hospital.
D. This study aims to determine the
sociodemographic of Staff Nurses in a
certain private hospital.
36 As a nurse, you know the
appropriate data gathering tool, this is?
A. Survey
B. Questionnaire
C. Structured Discussion
D. Interview Method
37. As a nurse, these are the following
topics in the scope and limitations except.
A Limited to the hospital personnel of a
private hospital
B. Limited only to the practice of
preventing needle prick injuries of nursing
personnel C. The scope of the study
involves the knowledge about prevention
of needle prick injunes
D. The scope of the study involves the
sociodemographic profile of nursing
Personnel
38. Which of the following is not a null
hypothesis?
A. There is no relationship between
the level of knowledge and practice of
prevention of needle prick injuries B.
There is no relationship between the
practice of prevention of needle prick
injuries and sociodemographic profile
of staff nurses
C. There is a significant relationship
between the knowledge and
sociodemographic profile of staff nurses in
a certain private hospital. D. All of the
above.
E. None of the above
39. Which of the following would
correspond to Intervene in Nursing
Process?
A. Select design plan
B. Report findings
C. Implement planned study
D. Select a plan analysis
40. Which of the following would
correspond to Plan in Nursing Process?
A. Select design plan
B. Report findings
C. implement planned study D.
Change the objectives after
implementation
41. When it comes to steps in Problem
Solving. Which of the following would be
similar in research where in you implement
the planned study? A. Theorize about facts
and possible
B. Gather, analyze relevant information–
C. Report findings
D. Determine information needs
42. Using the Research perspective, when
is the time that a nurse makes inferences?
A. Define purpose of review of literature
B. Formulate a problem, define variables
C. Select design sample
D. Report findings
43. Which of the following is does not
belong to the group?
A. Assess; Identify the problem
B. Plan: Theorize
C. Intervene: Gather relevant information
D. Evaluate Outcomes
44. In selecting a problem, these are the
following consideration except:
A. Time Factor
B. Talents
C. Cost
D. Data availability
45. These are the purpose of Review
of Related Literature except: A.
Reveal investigations
B. Reveal sources of data
C. Reveal what is the problem– D.
Reveal the significant research
personalities
46. As a nurse, you know the following a
function of theoretical framework, except:
A. Specifies relationship among the
concepts
B. Give a graphic view of the data
C. Clarifies the concept on which the study
is built
D. State assumptions
47. Which of the following would not be
Qualitative Research?
A. Case study of Myocardial Infarction
B. A Review on Corona Trial
C. A Review on the Nursing Uniform
D. A Review on the Performance in
Related Learning Experience of student
nurses
48. Using statistics in nursing research is a
very vital tool in presenting the data. As a
nurse you know the definition of sampling
as:
A. Taking certain areas of the population
dividing the areas into sections B.
Process of selecting a portion of the
population to represent the entire
population
C. Using every Nth name from the list
of participants
D. Taking any sample as long as it
comes up with the quota
49. A researcher plans to conduct a survey
It the population on Marupok City is 67, 666,
find the sample size it the margin of error is
23%.
A. 19
B. 15
C. 23
D. 29
50. The nurse develops the following
hypothesis: Elderly women receive less
aggressive treatment for breast cancer than
do younger women. Which variable would
be considered to be the dependent
variable?
A. Degree of treatment received
B. Age of the patient
C. Type of cancer being treated
D. Use of inpatient treatment
51. in planning care for a newly admitted
patient with depression, the highest priority
for the nurse is
A. orienting the patient to the unit.
B. encouraginq expression of feelings.
C. providing a safe environment D. meeting
the patient at an appropriato affective
level.
52. A patient displays disorganized, difficult
to understand speech, behavioral
disorganization, and a silly, inappropriate
affect The patient prefers to sit alone and
be uninvolved in unit activities, and often
appears to be listening and responding to
unseen stimuli. The nursing diagnosis that
should be given priority is:
A. impaired verbal communication***
B. social isolation.
C. ineffective coping.
D. impaired social interaction.
53. The nurse should focus assessment for
a patient with type 1 schizophrenia primarily
on gathering data about:
A. communication difficulties.
B. perceptual alterations.
C. social interactions.
D. avolition.
54. A withdrawn patient exhibits peculiar
gestures and waxy flexibility. She repeats
what the nurse says to her in a high-pitched
voice but does not otherwise respond
verbally. The nurse should document that
the patient demonstrates: A. echolalia.
B. alogia
C. concrete thinking.
D. associative looseness.
55. The emergency room phones the
psychiatric unit to say that a patient
demonstrating symptoms of acute
schizophrenia, including altered
perceptions, is being admitted. The nurse
can anticipate care by considering that the
type of perceptual alteration most
commonly displayed by patients with
schizophrenia is: A. waxy flexibility.
B. auditory hallucinations.
C. inappropriate affect.
D. loose associations.
56. A patient relates the following history Ile
Plebence of continuous, intrusive thought
her house is contaminated with lethal
bacteria, and the uncontrollable urge to
continuously clean the walls, Moors, and
furniture. These symptoms are most
consistent with the DSM-/V-TR diagnosis ot
A. social phobia.
B. panic disorder.
C. somatoform disorder
D. obsessive-compulsive disorder
57. A patient whose husband was killed in
the World Trade Center explosion has
become unwilling to enter a tall building
because she experiences severe physical
and emotional symptoms when she does,
During these episodes, she becomes
diaphoretic, her heart races, and she feels
as though she cannot breathe. She is filled
with dread, thinking that the building will
explode The nurse can assess these
symptoms as being most consistent with the
diagnosis of
A. obsessive-compulsive disorder
B. generalized anxiety disorder
C. acute stress disorder.
D. specific phobia.
58. When working with a patient who has
dissociative amnesia, the nurse should plan
to begin by
A. taking measures to prevent identity
diffusion
B. setting mutual goals for behavioral
changes
C. helping the patient develop a
realistic self- concept.
D. identifying and supporting patient
strengths
59. The nurse notes that a patient with
obsessive- compulsive disorder (OCD) is
pacing up and down the corridor while
counting each circuit. The best action on the
part of the nurse Would be to: A. ask her
why she is pacing and cousin B. take her
by the arm and lead her to her room
C. offer to play cards with her in the
dayroom
D. permit her to pace and count until
she's comfortable
60. A principle that should be applied when
providing care for a patient with conversion
disorder is
A. give attention to the patient, not the
symptom
B. structure care to provide time for
rituals C. facilitate progressive review of the
trauma.
D. permit dependence while the symplo is
present.
61. Which symptom related to
disordered communication is the nurse
most likely to assess in a patient who is
having a manic episode? A. Mutism
B. Flight of ideas
C. Loose associations
D. echolalia
62. A principle of greatest value when
interacting with a patient who is
experiencing a manic episode is:
A. use a calm matter of fact approach
B. avoid mentioning limits
C. do not interrupt patient
D. encourage joking
63. A nursing diagnosis that can be
established for a grossly hyperactive manic
patients who runs wherever he goes,
exercises wildly, and is argumentative with
other patients is :
A. powerlessness
B. risk for injury
C. deficient diversional activity
D. disturbed thought processes
64. During community meeting, a manic
patient tells another patient, You need to
push yourself away from the table more.
You're too fat for your own good!" The
nurse should intervene by:
A. calmly telling the patient that unit
rules do not permit insulting others,
B. telling the patient that he must leave
the meeting and go to his room.
C. telling the patient that he can remain
in the meeting only if he apologizes.
D. suggesting that the patient take prn
medication.
65. A patient with bipolar I disorder is
noted to be laughing and giddy one minute
and within seconds is angry and sarcastic.
The assessment that the nurse should
make is that the patient's mood is: A.
incongruent.
B. inappropriate.
C. incandescent.
D. labile.
66. A psychiatric technician mentions to
the nurse, "I think I heard the ED doctor
say that the patient I just brought to the unit
has a personality disorder." To follow up on
this, the nurse could look at the diagnostic
sheet under the DSM-IV-TR axis
A. I
B. II
C. III
D. IV
67. A nursing diagnosis appropriate to
consider for a patient with any of the
personality disorders is: A. noncompliance.
B. impaired social interaction.
C. disturbed personal identity.
D. disturbed sensory perception.
68. A patient who is suspicious of the
motives of others has had a long-time feud
with his two siblings over their parents' wills.
He reacts quickly with anger whenever he
thinks that someone is threatening his
welfare. The nurse would assess these
characteristics as being most consistent
with the profile known as:
A. schizoid personality.
B. paranoid personality .
C. borderline personality.
D. narcissistic personality.
69. The characteristic of individuals with
dramatic erratic personality disorders that
makes it advisable for staff to have frequent
patient- centered meetings is the individuals
propensity for :
A. Behaving responsibly in the peer grou
B. Quickly and successfully adapting to
stress
C. manipulating others to evade limits D.
coping successfully with a stressful
Environment.
70. A 27-year-old is admitted for
diagnostic Workup. She is described as
having a history of frequent intoxication
and promiscuity. Recently, she has stolen
money from her grandmother to finance a
trip to Las Vegas with her new boyfriend.
She indicates that she is not sorry for
stealing the money. Only sorry that her
grandmother pressed charges instead of
"being a good sport." The nurse assesses
this as being consistent with:
A. conduct disorder
 B. narcissistic personality disorder.???
C. antisocial personality disorder.
D. Borderline personality disorder.
71. The wife of a patient with a sexual
disorder asks, "What's a paraphilia?" The
nurse, who knows that the physician has
talked to the patient and spouse and has
used this term, assumes that the spouse is
seeking information. The nurse should
respond:
A. "Any homosexual act:
B. "Inhibition of the sexual response cycle
C . "Intense sexual urges with an
abnormal focus.
D. "Discomfort with one's biological
gender."
72. When working with a patient
regarding sexual concerns, a necessity
for providing nonjudgmental care is: A.
limit setting.
B. assertiveness training.
C. sexual self-awareness.
D. effective communication
73. A patient with premature ejaculation
tells the nurse, "I feel like such a failure. It's
so awful for both me and my wife. Do you
have any suggestions that would be
helpful?" The remark that clarifies the
nurse's role is:
A. "Sex therapy isn't my specialty, but
I will try to help.
B. "I can refer you to the sexual
disorders clinic to see a physician who
specializes in this disorder" C. "Have you
spoken with your physician about using
Viagra?"
D. "There are several techniques here in
this pamphlet that might be helpful."
74. A patient who is a pedophile tells the
nurse that he is feeling a huge amount of
guilt and shame over molesting a child. He
is concerned about the impact on his family
and states that the family would be better
off without him. The nurse should: A.
explore his feelings in greater depth.
B. set limits on patient disclosure
C. consider instituting suicide
precaution
D. provide prn anxiolytic medication.
75. A 56-year-old man has been feeling
much tension since losing his job. He
leaves home one morning and, while sitting
in the park feeding birds, impulsively
exposes himself publicly to a group of
mothers and children. This behavior should
be assessed as:
A. voyeurism.
B. dyspareunia.
C. exhibitionism.
D. sexual masochism.
76. When assessing a patient with
cognitive disorder, the nurse should base
observations on knowledge that the
foundation of the cognitive process is:
A. memory
B. reasoning.
C. orientation,
D. perception.
77. The highest priority for nursing care
for a patient with dementia is A.
improving cognition.
B. individualizing care .
C. maintaining an optimal level of function
D. promoting self-confidence and self-
esteem.
78. An elderly individual is having difficulty
recognizing ordinary objects such as pencils
and water faucets. When he fails to think of
the word, he describes the function of the
Object- "that thing that writes" or "the thing
that gives water." The nurse assesses this
as
A. apraxia.
B. aphasia.
C. agnosia.
D. amnesia.
79. The nurse notes that an elderly patient
has fluctuating levels of awareness. She
seems anxious. She tells the nurse that she
saw her granddaughter standing at the foot
of the bed during the night. Later, the nurse
sees her moving her hands as though
picking things out of the air. The nurse
should suspect:
A delirium.
B. dementia.
C bipolar disorder.
D. schizophrenia.??
80. The patient need that is of
primary importance in the care of a
patient with severe Alzheimer's
disease is: A. promotion of self-care
activities. B. maintenance of nutrition
and hydration
C. demands that exceed capacity to
function.
D. periodic change of routine and
environment.
81. A patient with anorexia nervosa has the
nursing diagnosis "imbalanced nutrition:
less than body requirements related to
inadequate food intake." The expected
outcome should be that the patient will:
A. gain 1 to 3 pounds weekly B.
exhibit fewer signs of malnutrition.
C. restore healthy eating patterns and
normalize weight.
D. identify cognitive distortions about
weight and shape.
82. When a patient with anorexia
nervosa spills milk over her plate of
partially eaten food, the best approach
for the nurse to take would be to say A.
"Nice try, but it won't work." B Why are
you deliberately making mealtime
difficult?
C. "I'll get you another plate of food so
you can finish."
D. That little trick will cost you television
privileges.
83. A personality characteristic the
nurse would expect to find in a patient
with an eating disorder is: A.
extroversion.
B. high self-esteem.
C. perfectionism.
D. callous disregard for other
84. School nurses should be
particularly vigilant for signs of eating
disorders: A. in fourth graders.
B. among unpopular, studious high
school boys
C. among popular, high-achieving high
school girls.
D. at transitions from elementary to
middle school and middle school to high
school.
85. The nurse caring for individuals with
eating disorders should determine that the
general way in which bulimic and anorexic
individuals differ is:
A. indiscernible
B. anorexia is life-threatening; bulimia is not
C. bulimia has a biologic origin; anorexia
does not.
D. patients with anorexia are proud of their
eating habits; patients with bulimia are
ashamed.
 86. A patient asks the nurse, "How would I
know if I were dependent on alcohol?" The
nurse should respond by telling the patient
that dependence is defined by:
A. a compulsion to use the drug
B. a loss of control over use of the drug.
C. a physiologic need to use the drug. D.
continued use despite adverse
consequences.
87. The wife of an individual who is
alcohol- dependent asks the nurse, "What
do you mean when you ask if my husband
ever experienced a blackout?" The best
explanation would be that "A blackout is:
A. a comatose period related to alcohol
withdrawal."
B. a comatose period related to alcohol
intoxication."
C. a time period in which the person is
'passed out."
D. a period of time in which the person
under the influence of alcohol functions
normally but later is unable to remember.
88. The nurse would suspect a disulfiram
(Antabuse)-alcohol reaction when a patient
presents with symptoms of:
A. skin rash, itching, and urticaria.
B. pallor, hypotension, and muscle
cramping.
C. dry skin bradycardia fatigue, and
headache
D. headache dyspnea, nausea, vomiting,
and flushing
89. A patient report experiencing insomnia
and taking diazepam and wine in increasing
amounts to be able to sleep. The nurse
should teach the patient about: A. the
danger of ENS depression (CNS)
B. the risk of acetaldehyde toxicity
C. the risk of fetal alcohol syndrome D.
diazepam and dietary precautions
90. nurse assessing an individual who is a
multidrug abuser should ask about recent
use of the drug that produces the most
sustained high, which is:
A. crack
B. heroin.
C. cocaine.
D. methamphetamine
91. An important ECT pretreatment
responsibility of the nurse is to: A.
thoroughly assess the patient's
pretreatment level of functioning.
B. order and interpret skull and spine film
C. obtain informed consent for treatment.
D. prepare the light box for early morning
use
92. Which drug is the nurse most likely
To administer 30 to 45 minutes before
ECT?
A. Anectine
B. Atropine
C. Alprazolam
D. Amobarbital
93. An 8-year-old boy is referred to the
clinic for diagnosis and treatment. He is
described by his parents as disobedient
and argumentative. He has an explosive
temper and low frustration tolerance. Other
children relate poorly to him. These
behaviors are most consistent with the
medical diagnosis of:
A. autistic disorder.
B. conduct disorder.
C. oppositional defiant disorder.
D. attention-deficit/hyperactivity disorder.
94. The behaviors the nurse would expect
to document in a child who has Tourette's
syndrome are:
A. inattention and restlessness.
B. hostility and defiance.
C. body rocking and head banging.
D. involuntary motor movement and
vocalization.
95. A nursing diagnosis that would be
universally applicable for children with
autism is:
A. impaired social interaction related to
inability to relate to others.
B. anxiety related to disturbed thought
processes
C. chronic low self-esteem related to
excessive negative feedback.
D. deficient fluid volume related to
peculiar eating habits.
96. The nurse working with a victim of
spousal abuse should factor into care
planning the fact that a deterrent to
leaving the abusive situation is the
events that occur in the: A. tension-
building sage
B. honeymoon stage
C. battering incident.
D. processing stage
97. A woman who has been repeatedly
abused by her partner comes to the ED for
treatment of severe contusions. As her
injuries are being treated, she tells the
nurse "He almost killed me this time, I
quess I'm going to have to do something.
The priority intervention for the nurse is to:
A. tell the abuser to stop the abuse and
seek help.
B. Help the patient devise a safety or
escape plan.
build trust.
D. shifting blame for the incident from patient to perpetrator.
C. encourage the patient to take
independent action.
D. provide referrals contingent on the
patient leaving the abuser.
98. A survivor of childhood abuse enters
the hospital following an episode of wrist
cutting. The patient has a history of binge-
purge eating disorder and difficulty trusting
and relauna to others. A nursing
intervention of high priority is:
A. setting limits on self-harmful behavior.
B. fostering belief in and valuing family C.
encouraging sharing of blame for the
abuse with the perpetrator.
D. identifying and confronting abnormal
responses and feelings
99. The nurse caring for victims of
violence should plan care based on the
understanding that most victims begin to
react emotionally to the effect that the crime
has on their lives. This stage of recovery is
known as: A. impact
B.recoil
C.reorganization
D.retribution
100. In preparing a care plan for an
abuse victim, it is most important to include
a long-term outcome that addresses the
need for:
A. moving the individual from victim to
survivor status.
B. providing support groups for long-term
assistance.
C. using empathy to establish rapport and