1. C.

Check for any change in responsiveness every two hours until the follow-up
visit
Signs of an epidural hematoma in children usually do not appear for 24 hours or more
hours; a follow-up visit usually is arranged for one to two days after the injury.

2. A. Arteriolar constriction occurs

The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and
pulse pressure; blood is shunted to vital centers, particularly heart and brain.

3. A. Allow the client to open canned or pre-packaged food

The client’s comfort, safety, and nutritional status are the priorities; the client may feel
comfortable to eat if the food has been sealed before reaching the mental health facility.

4. D. “Joining a support group of parents who are coping with this problem can be
quite helpful.
Taking with others in similar circumstances provides support and allows for sharing of
experiences.

5. B. Observe the dressing at the back of the neck for the presence of blood
Drainage flows by gravity.

6. C. Prepare her for a pelvic examination

Pelvic examination would reveal dilation and effacement

7. D. On the right side of the heart

Pulmonic stenosis increases resistance to blood flow, causing right ventricular hyperthropy;
with right ventricular failure there is an increase in pressure on the right side of the heart.

8. A. Eating patterns are altered

A new dietary regimen, with a balance of foods from the food pyramid, must be established
and continued for weight reduction to occur and be maintained.

9. B. “It is Ok to cry; I’ll just stay with you for now”

This portrays a nonjudgmental attitude that recognizes the client’s needs.

10. C. Lactated Ringer’s solution

Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of
which commonly occur following a burn. Albumin is used as adjunct therapy, not primary
fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it
can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the
intracellular space to the plasma, so potassium would be detrimental.

11. C. Twitching and disorientation

Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in
sensitive brain cells causes altered mental status; other signs includeanorexia nervosa,
nausea, vomiting, twitching, sleepiness, and convulsions.
12. B. Resume the usual diet as soon as desired

As long as the client has no nausea or vomiting, there are no dietary restriction.

13. B. Shrinkage of the residual limb must be completed

Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial
fluid, must occur for an adequate fit between the limb and the prosthesis.

14. A. Change the maternal position

Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that
accompanies partial cord compression (umbilical vein) during contractions; changing the
maternal position can alleviate the compression.

15. A. Perform a finger stick to test the client’s blood glucose level

The client has signs of diabetes, which may result from steroid therapy, testing the blood
glucose level is a method of screening for diabetes, thus gathering more data.

16. C. Heart block

This is the primary indication for a pacemaker because there is an interfere with the
electrical conduction system of the heart.

17. A. With meals and snacks

Pancreases capsules must be taken with food and snacks because it acts on the nutrients
and readies them for absorption.

18. B. Put a hat on the infant’s head

Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and
oxygen demands are not increased.

19. C. Wear an Ultra-Filter mask when they are in the client’s room

Tubercle bacilli are transmitted through air currents; therefore personal protective
equipment such as an Ultra-Filter mask is necessary.

20. D. Cerebral cortex compression

Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial
nerve injury, which cause pupil dilation.

21. A.Mediastinal shift

Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous
return.

22. C. Prevent situations that may stimulate the cervix or uterus

Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be
avoided.

23. C. Severe shortness of breath

This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate
to meet the oxygen demands of the body.

24. A. Suction equipment

Respiratory complications can occur because of edema of the glottis or injury to the
recurrent laryngeal nerve.

25. A. Strong desire to improve her body image

Clients with anorexia nervosa have a disturbed self image and always see themselves as fat
and needing further reducing.

26. B. Attempting to reduce or limit situations that increase anxiety

Persons with high anxiety levels develop various behaviors to relieve their anxiety; by
reducing anxiety, the need for these obsessive-compulsive action is reduced.

27. C. Becomes fussy when frustrated and displays a shortened attention span

Shortened attention span and fussy behavior may indicate a change in intracranial pressure
and/or shunt malfunction.

28. B. Maintaining the ordered hydration

Promoting hydration maintains urine production at a higher rate, which flushes the bladder
and prevents urinary stasis and possible infection.

29. C. Taking the client’s pedal pulse in the affected limb

Monitoring a pedal pulse will assess circulation to the foot.

30. A. “Where are you?”

“Where are you?” is the best question to elicit information about the client’s orientation to
place because it encourages a response that can be assessed.

31. D. Bleeding from the venipuncture site

This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted
in a lowered circulating fibrinogen.

32. D. blowing pattern

Clients should use a blowing pattern to overcome the premature urge to push.
33. A. Cheeseburger and a malted

Of the selections offered, this is the highest in calories and protein, which are needed for
increased basal metabolic rate and for tissue repair.

34. B. Cyanotic lips and face

Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by
either decreased lung expansion or right to left shunting of blood.

35. A. Notify the physician of the findings because the level is dangerously high

Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be
taken.

36. C. Days 15 to 17

Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30
day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse.

37. C. Assure that informed consent has been obtained from the client

An invasive procedure such as amniocentesis requires informed consent.

38. D. Prevent development of respiratory distress

Respiratory distress or arrest may occur when the serum level of magnesium sulfate
reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12
mg/dl; the drug is withheld in the absence of deep tendon reflexes; the therapeutic serum
level is 5 to 8 mg/dl.

39. A. Obtaining the child’s daily weight

Weight monitoring is the most useful means of assessing fluid balance and changes in the
edematous state; 1 liter of fluid weighs about 2.2 pounds.

40. C. Reduces the inflammatory response of tissues

Corticosteroids act to decrease inflammation which decreases edema.

41. D. An audible click on hip manipulation

With specific manipulation, an audible click may be heard of felt as he femoral head slips
into the acetabulum.

42. B. Allow the denial but be available to discuss death

This does not remove client’s only way of coping, and it permits future movement through
the grieving process when the client is ready.
43. B. Divide food into four to six meals a day

The volume of food in the stomach should be kept small to limit pressure on the cardiac
sphincter.

44. B. “I feel washed out; there isn’t much left”

The client’s statement infers an emptiness with an associated loss.

45. A. Vitamin K is not absorbed

Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile;
bile enters the duodenum via the common bile duct.

46. D. Leg weakness with muscle cramps

Impulse conduction of skeletal muscle is impaired with decreased potassium levels,

muscular weakness and cramps may occur with hypokalemia.

47. D. Simian lines on the hands

This is characteristic finding in newborns with Down syndrome.

48. B. Eyes

Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which
may lead to blindness.

49. A. Accept the client’s decision without discussion

This is all the nurse can do until trust is established; facing the client to attend will disrupt
the group.

50. D. Provide a simple explanation of the procedure and continue to reassure the
client

The nurse should offer support and use clear, simple terms to allay client’s anxiety.

51. D. If I have difficulty in inserting the irrigating tube into the stoma”

This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.

52. C. Blood loss of 850 ml after a vaginal birth

Excessive blood loss predisposes the client to an increased risk of infection because of
decreased maternal resistance; they expected blood loss is 350 to 500 ml.

53. A. Provide frequent saline mouthwashes

This is soothing to the oral mucosa and helps prevent infection.

54. B. “Society makes people react in old ways”

The client is incapable of accepting responsibility for self-created problems and blames
society for the behavior.

55. A. Taste and smell

Swelling can obstruct nasal breathing, interfering with the senses of taste and smell.

56. A. Fatigue

Fatigue is a major problem caused by an increase in waste products because of catabolic

processes.

57. A. Offer the client assistance to the bathroom

Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up
or attempting to get up to the bathroom unassisted.

58. D. Turn completely over, sit momentarily without support, reach to be picked
up
These abilities are age-appropriate for the 6 month old child.

59. D. Feed the baby on the unaffected breast first until the affected breast heals

The most vigorous sucking will occur during the first few minutes of breastfeeding when the
infant would be on the unaffected breast; later suckling is less traumatic.

60. D. Place sterile cotton loosely in the external ear of the client

This would absorb the drainage without causing further trauma.

61. D. Airing their feelings regarding the transmission of the disease to the child

Discussion with parents who have children with similar problems helps to reduce some of
their discomfort and guilt.

62. A. Suspicious feelings

The nurse must deal with these feelings and establish basic trust to promote a therapeutic
milieu.

63. A. Surgical menopause will occur

When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian
hormones and initiating response.

64. D. Pointing out to the client that death can occur with malnutrition.
The client expects the nurse to focus on eating, but the emphasis should be placed on
feelings rather than actions.

65. B. Medication is not adequately effective

The expected effect should be more than a one point decrease in the pain level.

66. B. Assisting the parents to stimulate their baby through touch, sound, and
sight.

Stimuli are provided via all the senses; since the infant’s behavioral development is
enhanced through parent-infant interactions, these interactions should be encouraged.

67. D. Recognize himself as an independent person of worth

Academic deficits, an inability to function within constraints required of certain settings, and
negative peer attitudes often lead to low self-esteem.

68. B. Monitoring the child’s blood pressure

Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved,
and blood pressure monitoring is important.

69. A. Nursing unit manager

Controlled substance issues for a particular nursing unit are the responsibility of that unit’s
nurse manager.

70. D. Encourage coughing, deep breathing, and range of motion to the arm on the
affected side

All these interventions promote aeration of the re-expanding lung and maintenance of
function in the arm and shoulder on the affected side.

71. A. For people to attain their birthrights of health and longevity

According to Winslow, all public health efforts are for people to realize their birthrights of
health and longevity.

72. C. Swaroop’s index

Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse
represents the percentage of untimely deaths (those who died younger than 50 years).

73. D. Public health nursing focuses on preventive, not curative, services.

The catchment area in PHN consists of a residential community, many of whom are well
individuals who have greater need for preventive rather than curative services.

74. B. Ensure the accessibility and quality of health care

Ensuring the accessibility and quality of health care is the primary mission of DOH.

75. B. Efficiency

Efficiency is determining whether the goals were attained at the least possible cost.

76. D. Rural Health Unit

R.A. 7160 devolved basic health services to local government units (LGU’s ). The public
health nurse is an employee of the LGU.

77. A. Act 3573

Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the
reporting of diseases listed in the law to the nearest health station.

78. A. Primary

The purpose of isolating a client with a communicable disease is to protect those who are
not sick (specific disease prevention).

79. B. It provides an opportunity to do first hand appraisal of the home situation.

Choice A is not correct since a home visit requires that the nurse spend so much time with
the family. Choice C is an advantage of a group conference, while choice D is true of a clinic
consultation.

80. B. Should minimize if not totally prevent the spread of infection.

Bag technique is performed before and after handling a client in the home to prevent
transmission of infection to and from the client.

81. A. Bag technique is performed before and after handling a client in the home to
prevent transmission of infection to and from the client.
Path Goal theory according to House and associates rewards good performance so that
others would do the same.

82. D. Inspires others with vision

Inspires others with a vision is characteristic of a transformational leader. He is focused

more on the day-to-day operations of the department/unit.

83. A. Psychological and sociological needs are emphasized.

When the functional method is used, the psychological and sociological needs of the patients
are neglected; the patients are regarded as ‘tasks to be done”

84. B. Preparing a nursing care plan in collaboration with the patient

The best source of information about the priority needs of the patient is the patient himself.
Hence using a nursing care plan based on his expressed priority needs would ensure
meeting his needs effectively.
85. C. Unity of command

The principle of unity of command means that employees should receive orders coming
from only one manager and not from two managers. This averts the possibility of sowing
confusion among the members of the organization.

86. A. Increase the patient satisfaction rate

Goal is a desired result towards which efforts are directed. Options AB, C and D are all
objectives which are aimed at specific end.

87. A. Uses visioning as the essence of leadership

Transformational leadership relies heavily on visioning as the core of leadership.

88. C. Avoidance

This strategy shuns discussing the issue head-on and prefers to postpone it to a later time.
In effect the problem remains unsolved and both parties are in a lose-lose situation.

89. A. Staffing

Staffing is a management function involving putting the best people to accomplish tasks and
activities to attain the goals of the organization.

90. B. Decentralized

Decentralized structures allow the staff to make decisions on matters pertaining to their
practice and communicate in downward, upward, lateral and diagonal flow.

91. D. end each entry with the nurse's signature and title.

The end of each entry should include the nurse's signature and title; the signature holds the
nurse accountable for the recorded information. Erasing errors in documentation on a legal
document such as a client's chart isn't permitted by law. Because a client's medical record is
considered a legal document, the nurse should make all entries in ink. The nurse is
accountable for the information recorded and therefore shouldn't leave any blank lines in
which another health care worker could make additions.

92. A. Allergies and socioeconomic status

General background data consist of such components as allergies, medical history, habits,
socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and
bowel habits are significant only if a disease affecting these functions is present.

93. C. I.V. cannula insertion

Caregivers must use surgical asepsis when performing wound care or any procedure in
which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis,
objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires
surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a
vein). The other options are used to ensure medical asepsis or clean technique to prevent
the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a
colostomy requires only clean technique.

94. B. Pouring solution onto a sterile field cloth

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture
penetrating the cloth can carry microorganisms to the sterile field via capillary action. The
other options are practices that help ensure surgical asepsis.

95. C. Impaired gas exchange

The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and
an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2),
supporting the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a
diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic
acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate
respiratory, not metabolic, acidosis.

96. A. Stream seeding

Stream seeding is done by putting tilapia fry in streams or other bodies of water identified
as breeding places of the Anopheles mosquito.

97. B. Severe dehydration

The order of priority in the management of severe dehydration is as follows: intravenous

fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes,
Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or
effective, tehn urgent referral to the hospital is done.

98. A. Inability to drink

A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has
one or more of the following signs: not able to feed or drink, vomits everything,
convulsions, abnormally sleepy or difficult to awaken.

99. A. Sugar

R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A,
iron and/or iodine.

100. A. Palms

The anatomic characteristics of the palms allow a reliable and convenient basis for
examination for pallor.