SET 2
evaluating the care during her shift. At the end of her shift,
PNLE I Nursing Practice
Scope of this Nursing Test I is parallel to the NP1 NLE
Coverage:
Foundation of Nursing
Nursing Research
Professional Adjustment
Leadership and Management
1. The registered nurse is planning to delegate tasks to
unlicensed assistive personnel (UAP). Which of the following
task could the registered nurse safely assigned to a UAP?
Monitor the I&O of a comatose toddler client with salicylate
poisoning
Perform a complete bed bath on a 2-year-old with multiple
injuries from a serious fall
Check the IV of a preschooler with Kawasaki disease
Give an outmeal bath to an infant with eczema
2. A nurse manager assigned a registered nurse from
telemetry unit to the pediatrics unit. There were three
patients assigned to the RN. Which of the following patients
should not be assigned to the floated nurse?
A 9-year-old child diagnosed with rheumatic fever
A young infant after pyloromyotomy
A 4-year-old with VSD following cardiac catheterization
A 5-month-old with Kawasaki disease
3. A nurse in charge in the pediatric unit is absent. The nurse
manager decided to assign the nurse in the obstetrics unit to
the pediatrics unit. Which of the following patients could the
nurse manager safely assign to the float nurse?
A child who had multiple injuries from a serious vehicle
accident
A child diagnosed with Kawasaki disease and with cardiac
complications
A child who has had a nephrectomy for Wilm’s tumor
A child receiving an IV chelating therapy for lead poisoning
4. The registered nurse is planning to delegate task to a
certified nursing assistant. Which of the following clients
should not be assigned to a CAN?
A client diagnosed with diabetes and who has an infected toe
A client who had a CVA in the past two months
A client with Chronic renal failure
A client with chronic venous insufficiency
5. The nurse in the medication unit passes the medications
for all the clients on the nursing unit. The head nurse is
making rounds with the physician and coordinates clients’
activities with other departments. The nurse assistant
changes the bed lines and answers call lights. A second nurse
is assigned for changing wound dressings; a licensed
practitioner nurse takes vital signs and bathes theclients. This
illustrates of what method of nursing care?
Case management method
Primary nursing method
Team method
Functional method
6. A registered nurse has been assigned to six clients on the
12-hour shift. The RN is responsible for every aspect of care
such as formulating the care of plan, intervention and
the RN will pass this same task to the next RN in charge. This
nursing care illustrates of what kind of method?
primary nursing method
case method
team method
functional method
7. A newly hired nurse on an adult medicine unit with 3
months experience was asked to float to pediatrics. The
nurse hesitates to perform pediatric skills and receive an
interesting assignment that feels overwhelming. The nurse
should:
resign on the spot from the nursing position and apply for a
position that does not require floating
Inform the nursing supervisor and the charge nurse on the
pediatric floor about the nurse’s lack of skill and feelings of
hesitations and request assistance
Ask several other nurses how they feel about pediatrics and
find someone else who is willing to accept the assignment
Refuse the assignment and leave the unit requesting a
vacation a day
8. An experienced nurse who voluntarily trained a less
experienced nurse with the intention of enhancing the skills
and knowledge and promoting professional advancement to
the nurse is called a:
mentor
team leader
case manager
change agent
9. The pediatrics unit is understaffed and the nurse manager
informs the nurses in the obstetrics unit that she is going to
assign one nurse to float in the pediatric units. Which
statement by the designated float nurse may put her job at
risk?
“I do not get along with one of the nurses on the pediatrics
unit”
“I have a vacation day coming and would like to take that
now”
“I do not feel competent to go and work on that area”
“ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a
medical unit for 3 weeks. The nurse manager has posted the
team leader assignments for the following week. The new
staff knows that a major responsibility of the team leader is
to:
Provide care to the most acutely ill client on the team
Know the condition and needs of all the patients on the team
Document the assessments completed by the team members
Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs
emergency surgery. The nurse prepared the consent form
and it should be signed by:
The Physician
The Registered Nurse caring for the client
The 15-year-old mother of the baby boy
The mother of the girl
12. A nurse caring to a client with Alzheimer’s disease
overheard a family member say to the client, “if you pee one
more time, I won’t give you any more food and drinks”. What
initial action is best for the nurse to take?
Take no action because it is the family member saying that to
the client
Talk to the family member and explain that what she/he has
said is not appropriate for the client
Give the family member the number for an Elder Abuse Hot
line
Document what the family member has said
13. Which is true about informed consent?
A nurse may accept responsibility signing a consent form if
the client is unable
Obtaining consent is not the responsibility of the physician
A physician will not subject himself to liability if he withholds
any facts that are necessary to form the basis of an intelligent
consent
If the nurse witnesses a consent for surgery, the nurse is, in
effect, indicating that the signature is that of the purported
person and that the person’s condition is as indicated at the
time of signing
14. A mother in labor told the nurse that she was expecting
that her baby has no chance to survive and expects that the
baby will be born dead. The mother accepts the fate of the
baby and informs the nurse that when the baby is born and
requires resuscitation, the mother refuses any treatment to
her baby and expresses hostility toward the nurse while the
pediatric team is taking care of the baby. The nurse is legally
obligated to:
Notify the pediatric team that the mother has refused
resuscitation and any treatment for the baby and take the
baby to the mother
Get a court order making the baby a ward of the court
Record the statement of the mother, notify the pediatric
team, and observe carefully for signs of impaired bonding
and neglect as a reasonable suspicion of child abuse
Do nothing except record the mother’s statement in the
medical record
15. The hospitalized client with a chronic cough is scheduled
for bronchoscopy. The nurse is tasks to bring the informed
consent document into the client’s room for a signature. The
client asks the nurse for details of the procedure and
demands an explanation why the process of informed
consent is necessary. The nurse responds that informed
consent means:
The patient releases the physician from all responsibility for
the procedure.
The immediate family may make decision against the
patient’s will.
The physician must give the client or surrogates enough
information to make health care judgments consistent with
their values and goals.
The patient agrees to a procedure ordered by the physician
even if the client does not understand what the outcome will
be.
16. A hospitalized client with severe necrotizing ulcer of the
lower leg is schedule for an amputation. The client tells the
nurse that he will not sign the consent form and he does not
want any surgery or treatment because of religious beliefs
about reincarnation. What is the role of the RN?
call a family meeting
discuss the religious beliefs with the physician
encourage the client to have the surgery
inform the client of other options
17. While in the hospital lobby, the RN overhears the three
staff discussing the health condition of her client. What
would be the appropriate nursing action for the RN to take?
Tell them it is not appropriate to discuss the condition of the
client
Ignore them, because it is their right to discuss anything they
want to
Join in the conversation, giving them supportive input about
the case of the client
Report this incident to the nursing supervisor
18. A staff nurse has had a serious issue with her colleague. In
this situation, it is best to:
Discuss this with the supervisor
Not discuss the issue with anyone. It will probably resolve
itself
Try to discuss with the colleague about the issue and resolve
it when both are calmer
Tell other members of the network what the team member
did
19. The nurse is caring to a client who just gave birth to a
healthy baby boy. The nurse may not disclose confidential
information when:
The nurse discusses the condition of the client in a clinical
conference with other nurses
The client asks the nurse to discuss the her condition with the
family
The father of a woman who just delivered a baby is on the
phone to find out the sex of the baby
A researcher from an institutionally approved research study
reviews the medical record of a patient
20. A 17-year-old married client is scheduled for surgery. The
nurse taking care of the client realizes that consent has not
been signed after preoperative medications were given.
What should the nurse do?
Call the surgeon
Ask the spouse to sign the consent
Obtain a consent from the client as soon as possible
Get a verbal consent from the parents of the client
21. A 12-year-old client is admitted to the hospital. The
physician ordered Dilantin to the client. In administering IV
phenytoin (Dilantin) to a child, the nurse would be most
correct in mixing it with:
Normal Saline
Heparinized normal saline
5% dextrose in water
Lactated Ringer’s solution
22. The nurse is caring to a client who is hypotensive.
Following a large hematemesis, how should the nurse
position the client?
Feet and legs elevated 20 degrees, trunk horizontal, head on
small pillow
Low Fowler’s with knees gatched at 30 degrees
Supine with the head turned to the left
Bed sloped at a 45 degree angle with the head lowest and the
legs highest
23. The client is brought to the emergency department after
a serious accident. What would be the initial nursing action of
the nurse to the client?
assess the level of consciousness and circulation
check respirations, circulation, neurological response
align the spine, check pupils, check for hemorrhage
check respiration, stabilize spine, check circulation
24. A nurse is assigned to care to a client with Parkinson’s
disease. What interventions are important if the nurse wants
to improve nutrition and promote effective swallowing of the
client?
Eat solid food
Give liquids with meals
Feed the client
Sit in an upright position to eat
25. During tracheal suctioning, the nurse should implement
safety measures. Which of the following should the nurse
implements?
limit suction pressure to 150-180 mmHg
suction for 15-20 seconds
wear eye goggles
remove the inner cannula
26. The nurse is conducting a discharge instructions to a
client diagnosed with diabetes. What sign of hypoglycemia
should be taught to a client?
warm, flushed skin
hunger and thirst
increase urinary output
palpitation and weakness
27. A client admitted to the hospital and diagnosed with
Addison’s disease. What would be the appropriate nursing
action to the client?
administering insulin-replacement therapy
providing a low-sodium diet
restricting fluids to 1500 ml/day
reducing physical and emotional stress
28. The nurse is to perform tracheal suctioning. During
tracheal suctioning, which nursing action is essential to
prevent hypoxemia?
aucultating the lungs to determine the baseline data to
assess the effectiveness of suctioning
removing oral and nasal secretions
encouraging the patient to deep breathe and cough to
facilitate removal of upper-airway secretions
administering 100% oxygen to reduce the effects of airway
obstruction during suctioning.
29. An infant is admitted and diagnosed with pneumonia and
suspicious-looking red marks on the swollen face resembling
a handprint. The nurse does further assessment to the client.
How would the nurse document the finding?
Facial edema with ecchymosis and handprint mark: crackles
and wheezes
Facial edema, with red marks; crackles in the lung
Facial edema with ecchymosis that looks like a handprint
Red bruise mark and ecchymosis on face
30. On the evening shift, the triage nurse evaluates several
clients who were brought to the emergency department.
Which in the following clients should receive highest priority?
an elderly woman complaining of a loss of appetite and
fatigue for the past week
A football player limping and complaining of pain and
swelling in the right ankle
A 50-year-old man, diaphoretic and complaining of severe
chest pain radiating to his jaw
A mother with a 5-year-old boy who says her son has been
complaining of nausea and vomited once since noon
31. A 80-year-old female client is brought to the emergency
department by her caregiver, on the nurse’s assessment; the
following are the manifestations of the client: anorexia,
cachexia and multiple bruises. What would be the best
nursing intervention?
check the laboratory data for serum albumin, hematocrit,
and hemoglobin
talk to the client about the caregiver and support system
complete a police report on elder abuse
complete a gastrointestinal and neurological assessment
32. The night shift nurse is making rounds. When the nurse
enters a client’s room, the client is on the floor next to the
bed. What would be the initial action of the nurse?
chart that the patient fell
call the physician
chart that the client was found on the floor next to the bed
fill out an incident report
33. The nurse on the night shift is about to administer
medication to a preschooler client and notes that the child
has no ID bracelet. The best way for the nurse to identify the
client is to ask:
The adult visiting, “The child’s name is
____________________?”
The child, “Is your name____________?”
Another staff nurse to identify this child
The other children in the room what the child’s name is
34. The nurse caring to a client has completed the
assessment. Which of the following will be considered to be
the most accurate charting of a lump felt in the right breast?
“abnormally felt area in the right breast, drainage noted”
“hard nodular mass in right breast nipple”
“firm mass at five ‘ clock, outer quadrant, 1cm from right
nipple’
“mass in the right breast 4cmx1cm
35. The physician instructed the nurse that intravenous
pyelogram will be done to the client. The client asks the
nurse what is the purpose of the procedure. The appropriate
nursing response is to:
outline the kidney vasculature
determine the size, shape, and placement of the kidneys
test renal tubular function and the patency of the urinary
tract
measure renal blood flow
36. A client visits the clinic for screening of scoliosis. The
nurse should ask the client to:
bend all the way over and touch the toes
stand up as straight and tall as possible
bend over at a 90-degree angle from the waist
bend over at a 45-degree angle from the waist
37. A client with tuberculosis is admitted in the hospital for 2
weeks. When a client’s family members come to visit, they
would be adhering to respiratory isolation precautions when
they:
wash their hands when leaving
put on gowns, gloves and masks
avoid contact with the client’s roommate
keep the client’s room door open
38. An infant is brought to the emergency department and
diagnosed with pyloric stenosis. The parents of the client ask
the nurse, “Why does my baby continue to vomit?” Which of
the following would be the best nursing response of the
nurse?
“Your baby eats too rapidly and overfills the stomach, which
causes vomiting
“Your baby can’t empty the formula that is in the stomach
into the bowel”
“The vomiting is due to the nausea that accompanies pyloric
stenosis”
“Your baby needs to be burped more thoroughly after
feeding”
39. A 70-year-old client with suspected tuberculosis is
brought to the geriatric care facilities. An intradermal
tuberculosis test is schedule to be done. The client asks the
nurse what is the purpose of the test. Which of the following
would be the best rationale for this?
reactivation of an old tuberculosis infection
increased incidence of new cases of tuberculosis in persons
over 65 years old
greater exposure to diverse health care workers
respiratory problems are characteristic in this population
40. The nurse is making a health teaching to the parents of
the client. In teaching parents how to measure the area of
induration in response to a PPD test, the nurse would be
most accurate in advising the parents to measure:
both the areas that look red and feel raised
The entire area that feels itchy to the child
Only the area that looks reddened
Only the area that feels raised
41. A community health nurse is schedule to do home visit.
She visits to an elderly person living alone. Which of the
following observation would be a concern?
Picture windows
Unwashed dishes in the sink
Clear and shiny floors
Brightly lit rooms
42. After a birth, the physician cut the cord of the baby, and
before the baby is given to the mother, what would be the
initial nursing action of the nurse?
examine the infant for any observable abnormalities
confirm identification of the infant and apply bracelet to
mother and infant
instill prophylactic medication in the infant’s eyes
wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe
eczema lesions on the scalp, face, neck and arms. The client
is scratching the affected areas. What would be the best
nursing intervention to prevent the client from scratching the
affected areas?
elbow restraints to the arms
Mittens to the hands
Clove-hitch restraints to the hands
A posey jacket to the torso
44. The parents of the hospitalized client ask the nurse how
their baby might have gotten pyloric stenosis. The
appropriate nursing response would be:
There is no way to determine this preoperatively
Their baby was born with this condition
Their baby developed this condition during the first few
weeks of life
Their baby acquired it due to a formula allergy
45. A male client comes to the clinic for check-up. In doing a
physical assessment, the nurse should report to the physician
the most common symptom of gonorrhea, which is:
pruritus
pus in the urine
WBC in the urine
Dysuria
46. Which of the following would be the most important goal
in the nursing care of an infant client with eczema?
preventing infection
maintaining the comfort level
providing for adequate nutrition
decreasing the itching
47. The nurse is making a discharge instruction to a client
receiving chemotherapy. The client is at risk for bone marrow
depression. The nurse gives instructions to the client about
how to prevent infection at home. Which of the following
health teaching would be included?
“Get a weekly WBC count”
“Do not share a bathroom with children or pregnant woman”
“Avoid contact with others while receiving chemotherapy”
“Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious
disease. The best antimicrobial agent for the nurse to use in
handwashing is:
Isopropyl alcohol
Hexachlorophene (Phisohex)
Soap and water
Chlorhexidine gluconate (CHG) (Hibiclens)
49. The mother of the client tells the nurse, “ I’m not going to
have my baby get any immunization”. What would be the
best nursing response to the mother?
“You and I need to review your rationale for this decision”
“Your baby will not be able to attend day care without
immunizations”
“Your decision can be viewed as a form of child abuse and
neglect”
“You are needlessly placing other people at risk for
communicable diseases”
50. The nurse is teaching the client about breast self-
examination. Which observation should the client be taught
to recognize when doing the examination for detection of
breast cancer?
tender, movable lump
pain on breast self-examination
round, well-defined lump
dimpling of the breast tissue
Answers and Rationales
1. D. Bathing an infant with eczema can be safely
delegated to an aide; this task is basic and can
competently performed by an aid.
2. B. The RN floated from the telemetry unit would be
least prepared to care for a young infant who has just
had GI surgery and requires a specific feeding regimen.
3. C. RN floated from the obstetrics unit should be able to
care for a client with major abdominal surgery,
because this nurse has experienced caring for clients
with cesarean births.
4. A. The patient is experiencing a potentially serious
complication related to diabetes and needs ongoing
assessment by an RN
5. D. It describes functional nursing. Staff is assigned to
specific task rather than specific clients.
6. B. Case management. The nurse assumes total
responsibility for meeting the needs of the client
during her entire duty.
7. B. The nurse is ethically obligated to inform the person
responsible for the assignment and the person
responsible for the unit about the nurse’s skill level.
The nurse therefore avoids a situation of
abandoningclients and exposing them to greater risks
8. A. This describes a mentor
9. B. This action demonstrates a lack of responsibility and
the nurse should attempt negotiation with the nurse
manager.
10. B. The team leader is responsible for the overall
management of all clients and staff on the team, and
this information is essential in order to accomplish this
11. C. Even though the mother is a minor, she is legally
able to sign consent for her own child.
12. B. This response is the most direct and immediate.
This is a case of potential need for advocacy and
patient’s rights.
13. D. The nurse who witness a consent for treatment or
surgery is witnessing only that the client signed the
form and that the client’s condition is as indicated at
the time of signing. The nurse is not witnessing that
the client is “informed”.
14. C. Although the statements by the mother may not
create a suspicion of neglect, when they are coupled
with observations about impaired bonding and
maternal attachment, they may impose the obligation
to report child neglect. The nurse is further obligated
to notify caregivers of refusal to consent to treatment
15. C. It best explains what informed consent is and
provides for legal rights of the patient
16. B. The physician may not be aware of the role that
religious beliefs play in making a decision about
surgery.
17. A. The behavior should be stopped. The first step is to
remind the staff that confidentiality may be violated
18. C. Waiting for emotions to dissipate and sitting down
with the colleague is the first rule of conflict resolution.
19. C. The nurse has no idea who the person is on the
phone and therefore may not share the information
even if the patient gives permission
20. A. The priority is to let the surgeon know, who in turn
may ask the husband to sign the consent.
21. A. Phenytoin (Dilantin) can cause venous irritation due
to its alkalinity, therefore it should be mixed with
normal saline.
22. A. This position increases venous return, improves
cardiac volume, and promotes adequate ventilation
and cerebral perfusion
23. D. Checking the airway would be a priority, and a neck
injury should be suspected
24. D. Client with Parkinson’s disease are at a high risk for
aspiration and undernutrition. Sitting upright
promotes more effective swallowing.
25. C. It is important to protect the RN’s eyes from the
possible contamination of coughed-up secretions
26. D. There has been too little food or too much insulin.
Glucose levels can be markedly decreased (less than 50
mg/dl). Severe hypoglycemia may be fatal if not
detected
27. D. Because the client’s ability to react to stress is
decreased, maintaining a quiet environment becomes
a nursing priority. Dehydration is a common problem
in Addison’s disease, so close observation of the
client’s hydration level is crucial.
28. D. Presuctioning and postsuctioning ventilation with
100% oxygen is important in reducing hypoxemia
which occurs when the flow of gases in the airway is
obstructed by the suctioning catheter.
29. B. This is an example of objective data of both
pulmonary status and direct observation on the skin by
the nurse.
30. C. These are likely signs of an acute myocardial
infarction (MI). An acute MI is a cardiovascular
emergency requiring immediate attention. Acute MI is
potentially fatal if not treated immediately.
31. D. Assessment and more data collection are needed.
The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia
could result from medications, poor dentition, or
indigestion, and the bruises may be attributed to
ataxia, frequent falls, vertigo or medication.
32. B. This is closest to suggesting action-assessment,
rather than paperwork- and is therefore the best of the
four.
33. C. The only acceptable way to identify a preschooler
client is to have a parent or another staff member
identify the client.
34. C. It describes the mass in the greatest detail.
35. C. Intravenous pyelogram tests both the function and
patency of the kidneys. After the intravenous injection
of a radiopaque contrast medium, the size, location,
and patency of the kidneys can be observed by
roentgenogram, as well as the patency of the urethra
and bladder as the kidneys function to excrete the
contrast medium.
36. C. This is the recommended position for screening for
scoliosis. It allows the nurse to inspect the alignment
of the spine, as well as to compare both shoulders and
both hips.
37. A. Handwashing is the best method for reducing cross-
contamination. Gowns and gloves are not always
required when entering a client’s room.
38. B. Pyloric stenosis is an anomaly of the upper
gastrointestinal tract. The condition involves a
thickening, or hypertrophy, of the pyloric sphincter
located at the distal end of the stomach. This causes a
mechanical intestinal obstruction, which leads to
vomiting after feeding the infant. The vomiting
associated with pyloric stenosis is described as being
projectile in nature. This is due to the increasing
amounts of formula the infant begins to consume
coupled with the increasing thickening of the pyloric
sphincter.
39. B. Increased incidence of TB has been seen in the
general population with a high incidence reported in
hospitalized elderly clients. Immunosuppression and
lack of classic manifestations because of the aging
process are just two of the contributing factors of
tuberculosis in the elderly.
40. D. Parents should be taught to feel the area that is
raised and measure only that.
41. C. It is a safety hazard to have shiny floors because
they can cause falls.
42. D. The first priority, beside maintaining a newborn’s
patent airway, is body temperature.
43. B. The purpose of restraints for this child is to keep
the child from scratching the affected areas. Mittens
restraint would prevent scratching, while allowing the
most movement permissible.
44. C. Pyloric stenosis is not a congenital anatomical defect,
but the precise etiology is unknown. It develops during
the first few weeks of life.
45. B. Pus is usually the first symptom, because the
bacteria reproduce in the bladder.
46. A. Preventing infection in the infant with eczema is the
nurse’s most important goal. The infant with eczema is
at high risk for infection due to numerous breaks in the
skin’s integrity. Intact skin is always the infant’s first
line of defense against infection.
47. D. Frequent hand washing and good hygiene are the
best means of preventing infection.
48. D. CHG is a highly effective antimicrobial ingredient,
especially when it is used consistently over time.
49. A. The mother may have many reasons for such a
decision. It is the nurse’s responsibility to review this
decision with the mother and clarify any
misconceptions regarding immunizations that may
exist.
50. D. The tumor infiltrates nearby tissue, it can cause
retraction of the overlying skin and create a dimpling
appearance.
PNLE II Nursing Practice
The scope of this Nursing Test II is parallel to the NP2 NLE
Coverage:
Maternal and Child Health
Community Health Nursing
Communicable Diseases
Integrated Management of Childhood Illness
1. The student nurse is assigned to take the vital signs of the
clients in the pediatric ward. The student nurse reports to the
staff nurse that the parent of a toddler who is 2 days
postoperative after a cleft palate repair has given the toddler
a pacifier. What would be the best immediate action of the
nurse?
Notify the pediatrician of this finding
Reassure the student that this is an acceptable action on the
parent’s part
Discuss this action with the parents
Ask the student nurse to remove the pacifier from the
toddler’s mouth
2. The nurse is providing a health teaching to the mother of
an 8-year-old child with cystic fibrosis. Which of the following
statement if made by the mother would indicate to the nurse
the need for further teaching about the medication regimen
of the child?
“My child might need an extra capsule if the meal is high in
fat”
“I’ll give the enzyme capsule before every snack”
“I’ll give the enzyme capsule before every meal”
“My child hates to take pills, so I’ll mix the capsule into a cup
of hot chocolate
3. The mother brought her child to the clinic for follow-up
check up. The mother tells the nurse that 14 days after
starting an oral iron supplement, her child’s stools are black.
Which of the following is the best nursing response to the
mother?
“I will notify the physician, who will probably decrease the
dosage slightly”
“This is a normal side effect and means the medication is
working”
“You sound quite concerned. Would you like to talk about
this further?”
“I will need a specimen to check the stool for possible
bleeding”
4. An 8-year-old boy with asthma is brought to the clinic for
check up. The mother asks the nurse if the treatment given to
her son is effective. What would be the appropriate response
of the nurse?
I will review first the child’s height on a growth chart to know
if the treatment is working
I will review first the child’s weight on a growth chart to know
if the treatment is working
I will review first the number of prescriptions refills the child
has required over the last 6 months to give you an accurate
answer
I will review first the number of times the child has seen the
pediatrician during the last 6 months to give you an accurate
answer
5. The nurse is caring to a child client who is receiving
tetracycline. The nurse is aware that in taking this medication,
it is very important to:
Administer the drug between meals
Monitor the child’s hearing
Give the drug through a straw
Keep the child out of the sunlight
6. A 14 day-old infant with a cyanotic heart defects and mild
congestive heart failure is brought to the emergency
department. During assessment, the nurse checks the apical
pulse rate of the infant. The apical pulse rate is 130 beats per
minute. Which of the following is the appropriate nursing
action?
Retake the apical pulse in 15 minutes
Retake the apical pulse in 30 minutes
Notify the pediatrician immediately
Administer the medication as scheduled
7. The physician prescribed gentamicin (Garamycin) to a child
who is also receiving chemotherapy. Before administering
the drug, the nurse should check the results of the child’s:
CBC and platelet count
Auditory tests
Renal Function tests
Abdominal and chest x-rays
8. Which of the following is the suited size of the needle
would the nurse select to administer the IM injection to a
preschool child?
18 G, 1-1/2 inch
25 G, 5/8 inch
21 G, 1 inch
18 G, 1inch
9. A 9-year-old boy is admitted to the hospital. The boy is
being treated with salicylates for the migratory polyarthritis
accompanying the diagnosis of rheumatic fever. Which of the
following activities performed by the child would give a best
sign that the medication is effective?
Listening to story of his mother
Listening to the music in the radio
Playing mini piano
Watching movie in the dvd mini player
10. The physician decided to schedule the 4-year-old client
for repair of left undescended testicle. The Injection of a
hormone, HCG finds it less successful for treatment. To
administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the
nurse place him?
Supine with foot of bed elevated
Prone with legs abducted
Sitting with foot of bed elevated
Side-lying with upper leg flexed
11. The nurse is caring to a 24-month-old child diagnosed
with congenital heart defect. The physician prescribed
digoxin (Lanoxin) to the client. Before the administration of
the drug, the nurse checks the apical pulse rate to be 110
beats per minute and regular. What would be the next
nursing action?
Check the other vital signs and level of consciousness
Withhold the digoxin and notify the physician
Give the digoxin as prescribed
Check the apical and radial simultaneously, and if they are
the same, give the digoxin.
12. An 8-year-old client with cystic fibrosis is admitted to the
hospital and will undergo a chest physiotherapy treatment.
The therapy should be properly coordinated by the nurse
with the respiratory therapy department so that treatments
occur during:
After meals
Between meals
After medication
Around the child’s play schedule
13. The nurse is providing health teaching about the
breastfeeding and family planning to the client who gave
birth to a healthy baby girl. Which of the following statement
would alert the nurse that the client needs further teaching?
“I understand that the hormones for breastfeeding may
affect when my periods come”
“Breastfeeding causes my womb to tighten and bleed less
after birth”
“I may not have periods while I am breastfeeding, so I don’t
need family planning”
“I can get pregnant as early as one month after my baby was
born”
14. A toddler is brought to the hospital because of severe
diarrhea and vomiting. The nurse assigned to the client
enters the client’s room and finds out that the client is using
a soiled blanket brought in from home. The nurse attempts
to remove the blanket and replace it with a new and clean
blanket. The toddler refuses to give the soiled blanket. The
nurse realizes that the best explanation for the toddler’s
behavior is:
The toddler did not bond well with the maternal figure
The blanket is an important transitional object
The toddler is anxious about the hospital experience
The toddler is resistive to nursing interventions
15. The nurse has knowledge about the developmental task
of the child. In caring a 3-year-old-client, the nurse knows
that the suited developmental task of this child is to:
Learn to play with other children
Able to trust others
Express all needs through speaking
Explore and manipulate the environment
16. A mother who gave birth to her second daughter is so
concerned about her 2-year old daughter. She tells the nurse,
“I am afraid that my 2-year-old daughter may not accept her
newly born sister”. It is appropriate to the nurse to response
that:
The older daughter be given more responsibility and assure
her “that she is a big girl now, and doesn’t need Mommy as
much”
The older daughter not have interaction with the baby at the
hospital, because she may harm her new sibling
The older daughter stay with her grandmother for a few days
until the parents and new baby are settled at home
The mother spend time alone with her older daughter when
the baby is sleeping
17. A 2-year-old client with cystic fibrosis is confined to bed
and is not allowed to go to the playroom. Which of the
following is an appropriate toy would the nurse select for the
child:
Puzzle
Musical automobile
Arranging stickers in the album
Pounding board and hammer
18. Which of the following clients is at high risk for
developmental problem?
A toddler with acute Glomerulonephritis on antihypertensive
and antibiotics
A 5-year-old with asthma on cromolyn sodium
A preschooler with tonsillitis
A 2 1/2 –year old boy with cystic fibrosis
19. Which of the following would be the best divesionary
activity for the nurse to select for a 2 weeks hospitalized 3-
year-old girl?
Crayons and coloring books
doll
xylophone toy
puzzles
20. A nurse is providing safety instructions to the parents of
the 11-month-old child. Which of the following will the nurse
includes in the instructions?
Plugging all electrical outlets in the house
Installing a gate at the top and bottom of any stairs in the
home
Purchasing an infant car seat as soon as possible
Begin to teach the child not to place small objects in the
mouth
21. An 8-year-old girl is in second grade and the parents
decided to enroll her to a new school. While the child is
focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child
and forces her daughter to study after school. The father
does not allow also her daughter to play with other children.
These data indicate to the nurse that this child is deprived of
forming which normal phase of development?
Heterosexual relationships
A love relationship with the father
A dependency relationship with the father
Close relationship with peers
22. A 5-year-old boy client is scheduled for hernia surgery.
The nurse is preparing to do preoperative teaching with the
child. The nurse should knows that the 5-year-old would:
Expect a simple yet logical explanation regarding the surgery
Asks many questions regarding the condition and the
procedure
Worry over the impending surgery
Be uninterested in the upcoming surgery
23. The nine-year-old client is admitted in the hospital for
almost 1 week and is on bed rest. The child complains of
being bored and it seems tiresome to stay on bed and doing
nothing. What activity selected by the nurse would the child
most likely find stimulating?
Watching a video
Putting together a puzzle
Assembling handouts with the nurse for an upcoming staff
development meeting
Listening to a compact disc
24. The parent of a 16-year-old boy tells the nurse that his
son is driving a motorbike very fast and with one hand. “It is
making me crazy!” What would be the best explanation of
the nurse to the behavior of the boy?
The adolescent might have an unconscious death wish
The adolescent feels indestructible
The adolescent lacks life experience to realize how dangerous
the behavior is
The adolescent has found a way to act out hostility toward
the parent
25. An 8-month-old infant is admitted to the hospital due to
diarrhea. The nurse caring for the client tells the mother to
stay beside the infant while making assessment. Which of the
following developmental milestones the infant has reached?
Has a three-word vocabulary
Interacts with other infants
Stands alone
Recognizes but is fearful of strangers
26. The community nurse is conducting a health teaching in
the group of married women. When teaching a woman about
fertility awareness, the nurse should emphasize that the
basal body temperature:
Should be recorded each morning before any activity
Is the average temperature taken each morning
Can be done with a mercury thermometer but not a digital
one
Has a lower degree of accuracy in predicting ovulation than
the cervical mucus test
27. The community nurse is providing an instruction to the
clients in the health center about the use of diaphragm for
family planning. To evaluate the understanding of the woman,
the nurse asks her to demonstrate the use of the diaphragm.
Which of following statement indicates a need for further
health teaching?
“I should check the diaphragm carefully for holes every time I
use it.”
“The diaphragm must be left in place for at least 6 hours after
intercourse.”
“I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle
“I may need a different size diaphragm if I gain or lose more
than 20 pounds”
28. The client visits the clinic for prenatal check-up. While
waiting for the physician, the nurse decided to conduct
health teaching to the client. The nurse informed the client
that primigravida mother should go to the hospital when
which patter is evident?
Contractions are 2-3 minutes apart, lasting 90 seconds, and
membranes have ruptured
Contractions are 5-10 minutes apart, lasting 30 seconds, and
are felt as strong menstrual cramps
Contractions are 3-5 minutes apart, accompanied by rectal
pressure and bloody show
Contractions are 5 minutes apart, lasting 60 seconds, and
increasing in intensity
29. A nurse is planning a home visit program to a new mother
who is 2 weeks postpartum and breastfeeding, the nurse
includes in her health teaching about the resumption of
fertility, contraception and sexual activity. Which of the
following statement indicates that the mother has
understood the teaching?
“Because breastfeeding speeds the healing process after
birth, I can have sex right away and not worry about infection”
“Because I am breastfeeding and my hormones are
decreased, I may need to use a vaginal lubricant when I have
sex”
“After birth, you have to have a period before you can get
pregnant again’
“Breastfeeding protects me from pregnancy because it keeps
my hormones down, so I don’t need any contraception until I
stop breastfeeding”
30. A community nurse enters the home of the client for
follow-up visit. Which of the following is the most
appropriate area to place the nursing bag of the nurse when
conducting a home visit?
cushioned footstool
bedside wood table
kitchen countertop
living room sofa
31. The nurse in the health center is making an assessment to
the infant client. The nurse notes some rashes and small
fluid-filled bumps in the skin. The nurse suspects that the
infant has eczema. Which of the following is the most
important nursing goal:
Preventing infection
Providing for adequate nutrition
Decreasing the itching
Maintaining the comfort level
32. The nurse in the health center is providing immunization
to the children. The nurse is carefully assessing the condition
of the children before giving the vaccines. Which of the
following would the nurse note to withhold the infant’s
scheduled immunizations?
a dry cough
a skin rash
a low-grade fever
a runny nose
33. A mother brought her child in the health center for
hepatitis B vaccination in a series. The mother informs the
nurse that the child missed an appointment last month to
have the third hepatitis B vaccination. Which of the following
statements is the appropriate nursing response to the
mother?
“I will examine the child for symptoms of hepatitis B”
“Your child will start the series again”
“Your child will get the next dose as soon as possible”
“Your child will have a hepatitis titer done to determine if
immunization has taken place.”
34. The community health nurse implemented a new
program about effective breast cancer screening technique
for the female personnel of the health department of
Valenzuela. Which of the following technique should the
nurse consider to be of the lowest priority?
Yearly breast exam by a trained professional
Detailed health history to identify women at risk
Screening mammogram every year for women over age 50
Screening mammogram every 1-2 years for women over age
of 40.
35. Which of the following technique is considered an aseptic
practice during the home visit of the community health nurse?
Wrapping used dressing in a plastic bag before placing them
in the nursing bag
Washing hands before removing equipment from the nursing
bag
Using the client’s soap and cloth towel for hand washing
Placing the contaminated needles and syringes in a labeled
container inside the nursing bag
36. The nurse is planning to conduct a home visit in a small
community. Which of the following is the most important
factor when planning the best time for a home care visit?
Purpose of the home visit
Preference of the patient’s family
Location of the patient’s home
Length of time of the visit will take
37. The nurse assigned in the health center is counseling a
30-year-old client requesting oral contraceptives. The client
tells the nurse that she has an active yeast infection that has
recurred several times in the past year. Which statement by
the nurse is inaccurate concerning health promotion actions
to prevent recurring yeast infection?
“During treatment for yeast, avoid vaginal intercourse for
one week”
“Wear loose-fitting cotton underwear”
“Avoid eating large amounts of sugar or sugar-bingeing”
“Douche once a day with a mild vinegar and water solution”
38. During immunization week in the health center, the
parent of a 6-month-old infant asks the health nurse, “Why is
our baby going to receive so many immunizations over a long
time period?” The best nursing response would be:
“The number of immunizations your baby will receive shows
how many pediatric communicable and infectious diseases
can now be prevented.”
“You need to ask the physician”
“The number of immunizations your baby will receive is
determined by your baby’s health history and age”
“It is easier on your baby to receive several immunizations
rather than one at a time”
39. The community health nurse is conducting a health
teaching about nutrition to a group of pregnant women who
are anemic and are lactose intolerant. Which of the following
foods should the nurse especially encourage during the third
trimester?
Cheese, yogurt, and fish for protein and calcium needs plus
prenatal vitamins and iron supplements
Prenatal iron and calcium supplements plus a regular adult
diet
Red beans, green leafy vegetables, and fish for iron and
calcium needs plus prenatal vitamins and iron supplements
Red meat, milk and eggs for iron and calcium needs plus
prenatal vitamins and iron supplements
40. A woman with active tuberculosis (TB) and has visited the
health center for regular therapy for five months wants to
become pregnant. The nurse knows that further information
is necessary when the woman states:
“Spontaneous abortion may occur in one out of five women
who are infected”
“Pulmonary TB may jeopardize my pregnancy”
“I know that I may not be able to have close contact with my
baby until contagious is no longer a problem
“I can get pregnant after I have been free of TB for 6 months”
41. The Department of Health is alarmed that almost 33
million people suffer from food poisoning every year.
Salmonella enteritis is responsible for almost 4 million cases
of food poisoning. One of the major goals is to promote
proper food preparation. The community health nurse is
tasks to conduct health teaching about the prevention of
food poisoning to a group of mother everyday. The nurse can
help identify signs and symptoms of specific organisms to
help patients get appropriate treatment. Typical symptoms of
salmonella include:
Nausea, vomiting and paralysis
Bloody diarrhea
Diarrhea and abdominal cramps
Nausea, vomiting and headache
42. A community health nurse makes a home visit to an
elderly person living alone in a small house. Which of the
following observation would be a great concern?
Big mirror in a wall
Scattered and unwashed dishes in the sink
Shiny floors with scattered rugs
Brightly lit rooms
43. The health nurse is conducting health teaching about
“safe” sex to a group of high school students. Which of the
following statement about the use of condoms should the
nurse avoid making?
“Condoms should be used because they can prevent infection
and because they may prevent pregnancy”
“Condoms should be used even if you have recently tested
negative for HIV”
“Condoms should be used every time you have sex because
condoms prevent all forms of sexually transmitted diseases”
“Condoms should be used every time you have sex even if
you are taking the pill because condoms can prevent the
spread of HIV and gonorrhea”
44. The department of health is promoting the breastfeeding
program to all newly mothers. The nurse is formulating a plan
of care to a woman who gave birth to a baby girl. The nursing
care plan for a breast-feeding mother takes into account that
breast-feeding is contraindicated when the woman:
Is pregnant
Has genital herpes infection
Develops mastitis
Has inverted nipples
45. The City health department conducted a medical mission
in Barangay Marulas. Majority of the children in the Barangay
Marulas were diagnosed with pinworms. The community
health nurse should anticipate that the children’s chief
complaint would be:
Lack of appetite
Severe itching of the scalp
Perianal itching
Severe abdominal pain
46. The mother brought her daughter to the health center.
The child has head lice. The nurse anticipates that the nursing
diagnosis most closely correlated with this is:
Fluid volume deficit related to vomiting
Altered body image related to alopecia
Altered comfort related to itching
Diversional activity deficit related to hospitalization
47. The mother brings a child to the health care clinic
because of severe headache and vomiting. During the
assessment of the health care nurse, the temperature of the
child is 40 degree Celsius, and the nurse notes the presence
of nuchal rigidity. The nurse is suspecting that the child might
be suffering from bacterial meningitis. The nurse continues to
assess the child for the presence of Kernig’s sign. Which
finding would indicate the presence of this sign?
Flexion of the hips when the neck is flexed from a lying
position
Calf pain when the foot is dorsiflexed
Inability of the child to extend the legs fully when lying supine
Pain when the chin is pulled down to the chest
48. A community health nurse makes a home visit to a child
with an infectious and communicable disease. In planning
care for the child, the nurse must determine that the primary
goal is that the:
Child will experience mild discomfort
Child will experience only minor complications
Child will not spread the infection to others
Public health department will be notified
49. The mother brings her daughter to the health care clinic.
The child was diagnosed with conjunctivitis. The nurse
provides health teaching to the mother about the proper
care of her daughter while at home. Which statement by the
mother indicates a need for additional information?
“I do not need to be concerned about the spreading of this
infection to others in my family”
“I should apply warm compresses before instilling antibiotic
drops if purulent discharge is present in my daughter’s eye”
“I can use an ophthalmic analgesic ointment at nighttime if I
have eye discomfort”
“I should perform a saline eye irrigation before instilling, the
antibiotic drops into my daughter’s eye if purulent discharge
is present”
50. A community health nurse is caring for a group of flood
victims in Marikina area. In planning for the potential needs
of this group, which is the most immediate concern?
Finding affordable housing for the group
Peer support through structured groups
Setting up a 24-hour crisis center and hotline
Meeting the basic needs to ensure that adequate food,
shelter and clothing are available
Answers and Rationales
1. C. Nothing must be placed in the mouth of a toddler
who just undergone a cleft palate repair until the
suture line has completely healed. It is the nurse’s
responsibility to inform the parent of the client. Spoon,
forks, straws, and tongue blades are other
unacceptable items to place in the mouth of a toddler
who just undergone cleft palate repair. The general
principle of care is that nothing should enter the
mouth until the suture line has completely healed.
2. D. The pancreatic capsules contain pancreatic enzyme
that should be administered in a cold, not a hot,
medium (example: chilled applesauce versus hot
chocolate) to maintain the medication’s integrity.
3. B. When oral iron preparations are given correctly, the
stools normally turn dark green or black. Parents of
children receiving this medication should be advised
that this side effect indicates the medication is being
absorbed and is working well.
4. C. Reviewing the number of prescription refills the
child has required over the last 6 months would be the
best indicator of how well controlled and thus how
effective the child’s asthma treatment is. Breakthrough
wheezing, shortness of breath, and upper respiratory
infections would require that the child take additional
medication. This would be reflected in the number of
prescription refills.
5. D. Tetracycline may cause a phototoxic reaction.
6. D. The normal heart rate of an infant is 120-160 beats
per minute.
7. C. Both gentamicin and chemotherapeutic agents can
cause renal impairment and acute renal failure; thus
baseline renal function must be evaluated before
initiating either medication.
8. C. In selecting the correct needle to administer an IM
injection to a preschooler, the nurse should always
look at the child and use judgment in evaluating
muscle mass and amount of subcutaneous fat. In this
case, in the absence of further data, the nurse would
be most correct in selecting a needle gauge and length
appropriate for the “average’ preschool child. A
medium-gauge needle (21G) that is 1 inch long would
be most appropriate.
9. C. The purpose of the salicylate therapy is to relieve
the pain associated with the migratory polyarthritis
accompanying the rheumatic fever. Playing mini piano
would require movement of the child’s joints and
would provide the nurse with a means of evaluating
the child’s level of pain.
10. D. The recommended position to administer rectal
medications to children is side-lying with the upper leg
flexed. This position allows the nurse to safely and
effectively administer the medication while promoting
comfort for the child.
11. C. For a 12month-old child, 110 apical pulse rate is
normal and therefore it is safe to give the digoxin. A
toddler’s normal pulse rate is slightly lower than an
infant’s (120).
12. B. Chest physiotherapy treatments are scheduled
between meals to prevent aspiration of stomach
contents, because the child is placed in a variety of
positions during the treatment process.
13. C. It is common misconception that breastfeeding may
prevent pregnancy.
14. B. The “security blanket” is an important transitional
object for the toddler. It provides a feeling of comfort
and safety when the maternal figure is not present or
when in a new situation for which the toddler was not
prepared. Virtually any object (stuffed animal, doll,
book etc) can become a security blanket for the
toddler.
15. D. Toddlers need to meet the developmental
milestone of autonomy versus shame and doubt. In
order to accomplish this, the toddler must be able to
explore and manipulate the environment.
16. D. The introduction of a baby into a family with one or
more children challenges parent to promote
acceptance of the baby by siblings. The parent’s
attitudes toward the arrival of the baby can set the
stage for the other children’s reaction. Spending time
with the older siblings alone will also reassure them of
their place in the family, even though the older
children will have to eventually assume new positions
within the family hierarchy.
17. D. The autonomous toddler would be frustrated by
being confined to be. The pounding board and hammer
is developmentally appropriate and an excellent way
for the toddler to release frustration.
18. D. It is the developmental task of an 18-month-old
toddler to explore and learn about the environment.
The respiratory complications associated with cystic
fibrosis (which are present in almost all children with
cystic fibrosis) could prevent this development task
from occurring.
19. C. The best diversion for a hospitalized child aged 2-3
years old would be anything that makes noise or
makes a mess; xylophone which certainly makes noise
or music would be the best choice.
20. B. An 11-month-old child stands alone and can walk
holding onto people or objects. Therefore the
installation of a gate at the top and bottom of any
stairs in the house is crucial for the child’s safety.
21. D. In second grade a child needs to form a close
relationships with peers.
22. B. A 5-year-old is highly concerned with body integrity.
The preschool-age child normally asks many questions
and in a situation such as this, could be expected to ask
even more.
23. C. A 9-year-old enjoys working and feeling a sense of
accomplishment. The school-age child also enjoys
“showing off,” and doing something with the nurse on
the pediatric unit would allow this. This activity also
 provides the school-age child a needed opportunity to
interact with others in the absence of school and
personal friends.
24. B. Adolescents do feel indestructible, and this is
reflected in many risk-taking behaviors.
25. D. An 8-month-old infant both recognizes and is fearful
of strangers. This developmental milestone is known
as “stranger anxiety”.
26. A. The basal body temperature (BBT) is the lowest
body temperature of a healthy person that is taken
immediately after waking and before getting out of
bed. The BBT usually varies from 36.2 – 36.3 degree
Celsius during menses and for about 5-7 days
afterward. About the time of ovulation, a slight drop
approximately 0.05 degree Celsius in temperature may
be seen; after ovulation, in concert with the increasing
progesterone levels of the early luteal phase, the BBT
rises 0.2-0.4 degree Celsius. This elevation remains
until 2-3 days before menstruation, or if pregnancy has
occurred.
27. C. The woman must understand that, although the
“fertile” period is approximately midcycle, hormonal
variations do occur and can result in early or late
ovulations. To be effective, the diaphragm should be
inserted before every intercourse.
28. D. Although instructions vary among birth centers,
primigravidas should seek care when regular
contractions are felt about 5 minutes apart, becoming
longer and stronger.
29. B. Prolactin suppresses estrogen, which is needed to
stimulate vaginal lubrication during arousal.
30. B. A wood surface provides the least chance for
organisms to be present.
31. A. Preventing infection in the infant with eczema is the
nurse’s most important goal. The infant with eczema is
at high risk for infection due to numerous breaks in the
skin’s integrity. Intact skin is always the infant’s first
line of defense against infection.
32. B. A skin rash could indicate a concurrent infectious
disease process in the infant. The scheduled
immunizations should be withheld until the status of
the infant’s health can be determined. Fevers above
38.5 degrees Celsius, alteration in skin integrity, and
infectious-appearing secretions are indications to
withhold immunizations.
33. C. Continuity is essential to promote active immunity
and give hepatitis B lifelong prophylaxis. Optimally, the
third vaccination is given 6 months after the first.
34. B. Because of the high incidence of breast cancer, all
women are considered to be at risk regardless of
health history.
35. B. Handwashing is the best way to prevent the spread
of infection.
36. A. The purpose of the visit takes priority.
37. D. Frequent douching interferes with the natural
protective barriers in the vagina that resist yeast
infection and should be avoided.
38. A. Completion for the recommended schedule of infant
immunizations does not require a large number of
immunizations, but it also provides protection against
multiple pediatric communicable and infectious
diseases.
39. C. This is appropriate foods that are high in iron and
calcium but would not affect lactose intolerance.
40. D. Intervention is needed when the woman thinks that
she needs to wait only 6 months after being free of TB
before she can get pregnant. She needs to wait 1.5-
2years after she is declared to be free of TB before she
should attempt pregnancy.
41. C. Salmonella organisms cause lower GI symptoms
42. C. It is a safety hazard to have shiny floors and
scattered rugs because they can cause falls and rugs
should be removed.
43. C. Condoms do not prevent ALL forms of sexually
transmitted diseases.
44. A. Pregnancy is one contraindication to breast-feeding.
Milk secretion is inhibited and the baby’s sucking may
stimulate uterine contractions.
45. C. Perianal itching is the child’s chief complaint
associated with the diagnosis of pinworms. The itching,
in this instance, is often described as being “intense” in
nature. Pinworms infestation usually occurs because
the child is in the anus-to-mouth stage of development
(child uses the toilet, does not wash hands, places
hands and pinworm eggs in mouth). Teaching the child
hand washing before eating and after using the toilet
can assist in breaking the cycle.
46. C. Severe itching of the scalp is the classic sign and
symptom of head lice in a child. In turn, this would
lead to the nursing diagnosis of “altered comfort”.
47. C. Kernig’s sign is the inability of the child to extend
the legs fully when lying supine. This sign is frequently
present in bacterial meningitis. Nuchal rigidity is also
present in bacterial meningitis and occurs when pain
prevents the child from touching the chin to the chest.
48. C. The primary goal is to prevent the spread of the
disease to others. The child should experience no
complication. Although the health department may
need to be notified at some point, it is no the primary
goal. It is also important to prevent discomfort as
much as possible.
49. A. Conjunctivitis is highly contagious. Antibiotic drops
are usually administered four times a day. When
purulent discharge is present, saline eye irrigations or
eye applications of warm compresses may be
necessary before instilling the medication. Ophthalmic
analgesic ointment or drops may be instilled, especially
at bedtime, because discomfort becomes more
noticeable when the eyelids are closed.
50. D. The question asks about the immediate concern.
The ABCs of community health care are always
attending to people’s basic needs of food, shelter, and
clothing
PNLE III Nursing Practice
The scope of this Nursing Test III is parallel to the NP3 NLE
Coverage:
Medical Surgical Nursing
1. The nurse is going to replace the Pleur-O-Vac attached to
the client with a small, persistent left upper lobe
pneumothorax with a Heimlich Flutter Valve. Which of the
following is the best rationale for this?
Promote air and pleural drainage
Prevent kinking of the tube
Eliminate the need for a dressing
Eliminate the need for a water-seal drainage
2. The client with acute pancreatitis and fluid volume deficit
is transferred from the ward to the ICU. Which of the
following will alert the nurse?
Decreased pain in the fetal position
Urine output of 35mL/hr
CVP of 12 mmHg
Cardiac output of 5L/min
3. The nurse in the morning shift is making rounds in the
ward. The nurse enters the client’s room and found the client
in discomfort condition. The client complains of stiffness in
the joints. To reduce the early morning stiffness of the joints
of the client,the nurse can encourage the client to:
Sleep with a hot pad
Take to aspirins before arising, and wait 15 minutes before
attempting locomotion
Take a hot tub bath or shower in the morning
Put joints through passive ROM before trying to move them
actively
4. The nurse is planning of care to a client with peptic ulcer
disease. To avoid the worsening condition of the client, the
nurse should carefully plan the diet of the client. Which of
the following will be included in the diet regime of the client?
Eating mainly bland food and milk or dairy products
Reducing intake of high-fiber foods
Eating small, frequent meals and a bedtime snack
Eliminating intake of alcohol and coffee
5. The physician has given instruction to the nurse that the
client can be ambulated on crutches, with no weight bearing
on the affected limb. The nurse is aware that the appropriate
crutch gait for the nurse to teach the client would be:
Tripod gait
Two-point gait
Four-point gait
Three-point gait
6. The client is transferred to the nursing care unit from the
operating room after a transurethral resection of the
prostate. The client is complaining of pain in the abdomen
area. The nurse suspects of bladder spasms, which of the
following is the best nursing action to minimize the pain felt
by the client?
Advising the client not to urinate around catheter
Intermittent catheter irrigation with saline
Giving prescribed narcotics every 4 hour
Repositioning catheter to relieve pressure
7. A client is diagnosed with peptic ulcer. The nurse caring for
the client expects the physician to order which diet?
NPO
Small feedings of bland food
A regular diet given frequently in small amounts
Frequent feedings of clear liquids
8. The nurse is going to insert a Miller-Abbott tube to the
client. Before insertion of the tube, the balloon is tested for
patency and capacity and then deflated. Which of the
following nursing measure will ease the insertion to the tube?
Positioning the client in Semi-Fowler’s position
Administering a sedative to reduce anxiety
Chilling the tube before insertion
Warming the tube before insertion
9. The physician ordered a low-sodium diet to the client.
Which of the following food will the nurse avoid to give to
the client?
Orange juice.
Whole milk.
Ginger ale.
Black coffee.
10. Mr. Bean, a 70-year-old client is admitted in the hospital
for almost one month. The nurse understands that prolonged
immobilization could lead to decubitus ulcers. Which of the
following would be the least appropriate nursing intervention
in the prevention of decubitus?
Giving backrubs with alcohol
Use of a bed cradle
Frequent assessment of the skin
Encouraging a high-protein diet
11. The physician prescribed digoxin 0.125 mg PO qd to a
client and instructed the nurse that the client is on high-
potassium diet. High potassium foods are recommended in
the diet of a client taking digitalis preparations because a low
serum potassium has which of the following effects?
Potentiates the action of digoxin
Promotes calcium retention
Promotes sodium excretion
Puts the client at risk for digitalis toxicity
12. The nurse is caring for a client who is transferred from
the operating room for pneumonectomy. The nurse knows
that immediately following pneumonectomy; the client
should be in what position?
Supine on the unaffected side
Low-Fowler’s on the back
Semi-Fowler’s on the affected side
Semi-Fowler’s on the unaffected side
13. A client is placed on digoxin, high potassium foods are
recommended in the diet of the client. Which of the
following foods willthe nurse give to the client?
Whole grain cereal, orange juice, and apricots
Turkey, green bean, and Italian bread
Cottage cheese, cooked broccoli, and roast beef
Fish, green beans and cherry pie
14. The nurse is assigned to care to a client who undergone
thyroidectomy. What nursing intervention is important
during the immediate postoperative period following a
thyroidectomy?
Assess extremities for weakness and flaccidity
Support the head and neck during position changes
Position the client in high Fowler’s
Medicate for restlessness and anxiety
15. What would be the recommended diet the nurse will
implement to a client with burns of the head, face, neck and
anterior chest?
Serve a high-protein, high-carbohydrate diet
Encourage full liquid diet
Serve a high-fat diet, high-fiber diet
Monitor intake to prevent weight gain
16. A client with multiple fractures of both lower extremities
is admitted for 3 days ago and is on skeletal traction. The
client is complaining of having difficulty in bowel movement.
Which of the following would be the most appropriate
nursing intervention?
Administer an enema
Perform range-of-motion exercise to all extremities
Ensure maximum fluid intake (3000ml/day)
Put the client on the bedpan every 2 hours
17. John is diagnosed with Addison’s disease and admitted in
the hospital. What would be the appropriate nursing care for
John?
Reducing physical and emotional stress
Providing a low-sodium diet
Restricting fluids to 1500ml/day
Administering insulin-replacement therapy
18. Mr. Smith is scheduled for an above-the-knee amputation.
After the surgery he was transferred to the nursing care unit.
The nurse assigned to him knows that 72 hours after the
procedure the client should be positioned properly to
prevent contractures. Which of the following is the best
position to the client?
Side-lying, alternating left and right sides
Sitting in a reclining chair twice a day
Lying on abdomen several times daily
Supine with stump elevated at least 30 degrees
19. A client is scheduled to have an inguinal herniorraphy in
the outpatient surgical department. The nurse is providing
health teaching about post surgical care to the client. Which
of the following statement if made by the client would reflect
the need for more teaching?
“I should call the physician if I have a cough or cold before
surgery”
“I will be able to drive soon after surgery”
“I will not be able to do any heavy lifting for 3-6 weeks after
surgery”
“I should support my incision if I have to cough or turn”
20. Ms Jones is brought to the emergency room and is
complaining of muscle spasms, numbness, tremors and
weakness in the arms and legs. The client was diagnosed with
multiple sclerosis. The nurse assigned to Ms. Jones is aware
that she has to prevent fatigue to the client to alleviate the
discomfort. Which of the following teaching is necessary to
prevent fatigue?
Avoid extremes in temperature
Install safety devices in the home
Attend support group meetings
Avoid physical exercise
21. Mr. Stewart is in sickle cell crisis and complaining pain in
the joints and difficulty of breathing. On the assessment of
the nurse, his temperature is 38.1 ºC. The physician ordered
Morphine sulfate via patient-controlled analgesia (PCA), and
oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart
is risk for infection. A nursing intervention to assist in
preventing infection is:
Using standard precautions and medical asepsis
Enforcing a “no visitors” rule
Using moist heat on painful joints
Monitoring a vital signs every 2 hour
22. Mrs. Maupin is a professor in a prestigious university for
30 years. After lecture, she experience blurring of vision and
tiredness. Mrs. Maupin is brought to the emergency
department. On assessment, the nurse notes that the blood
pressure of the client is 139/90. Mrs. Maupin has been
diagnosed with essential hypertension and placed on
medication to control her BP. Which potential nursing
diagnosis will be a priority for discharge teaching?
Sleep Pattern disturbance
Impaired physical mobility
Noncompliance
Fluid volume excess
23. Following a needle biopsy of the kidney, which
assessment is an indication that the client is bleeding?
Slow, irregular pulse
Dull, abdominal discomfort
Urinary frequency
Throbbing headache
24. A client with acute bronchitis is admitted in the hospital.
The nurse assigned to the client is making a plan of care
regarding expectoration of thick sputum. Which nursing
action is most effective?
Place the client in a lateral position every 2 hour
Splint the patient’s chest with pillows when coughing
Use humified oxygen
Offer fluids at regular intervals
25. The nurse is going to assess the bowel sound of the client.
For accurate assessment of the bowel sound, the nurse
should listen for at least:
5 minutes
60 seconds
30 seconds
2 minutes
26. The nurse encourages the client to wear compression
stockings. What is the rationale behind in using compression
stockings?
Compression stockings promote venous return
Compression stockings divert blood to major vessels
Compression stockings decreases workload on the heart
Compression stockings improve arterial circulation
27. Mr. Whitman is a stroke client and is having difficulty in
swallowing. Which is the best nursing intervention is most
likely to assist the client?
Placing food in the unaffected side of the mouth
Increasing fiber in the diet
Asking the patient to speak slowly
Increasing fluid intake
28. Following nephrectomy, the nurse closely monitors the
urinary output of the client. Which assessment finding is an
early indicator of fluid retention in the postoperative period?

Periorbital edema
Increased specific gravity of urine
A urinary output of 50mL/hr
Daily weight gain of 2 lb or more
29. A nurse is completing an assessment to a client with
cirrhosis. Which of the following nursing assessment is
important to notify the physician?
Expanding ecchymosis
Ascites and serum albumin of 3.2 g/dl
Slurred speech
Hematocrit of 37% and hemoglobin of 12g/dl
30. Mr. Park is 32-year-old, a badminton player and has a
type 1 diabetes mellitus. After the game, the client complains
of becoming diaphoretic and light-headedness. The client
asks the nurse how to avoid this reaction. The nurse will
recommend to:
Allow plenty of time after the insulin injection and before
beginning the match
Eat a carbohydrate snack before and during the badminton
match
Drink plenty of fluids before, during, and after bed time
Take insulin just before starting the badminton match
31. A client is rushed to the emergency room due to serious
vehicle accident. The nurse is suspecting of head injury.
Which of the following assessment findings would the nurse
report to the physician?
CVP of 5mmHa
Glasgow Coma Scale score of 13
Polyuria and dilute urinary output
Insomnia
32. Mrs. Moore, 62-year-old, with diabetes is in the
emergency department. She stepped on a sharp sea shells
while walking barefoot along the beach. Mrs. Moore did not
notice that the object pierced the skin until later that evening.
What problem does the client most probably have?
Nephropathy
Macroangiopathy
Carpal tunnel syndrome
Peripheral neuropathy
33. A client with gangrenous foot has undergone a below-
knee amputation. The nurse in the nursing care unit knows
that the priority nursing intervention in the immediate post
operative care of this client is:
Elevate the stump on a pillow for the first 24 hours
Encourage use of trapeze
Position the client prone periodically
Apply a cone-shaped dressing
34. A client with a diagnosis of gastric ulcer is complaining of
syncope and vertigo. What would be the initial nursing
intervention by the nurse?
Monitor the client’s vital signs
Keep the client on bed rest
Keep the patient on bed rest
Give a stat dose of Sucralfate (Carafate)
35. After a right lower lobectomy on a 55-year-old client,
which action should the nurse initiate when the client is
transferred from the post anesthesia care unit?
Notify the family to report the client’s condition
Immediately administer the narcotic as ordered
Keep client on right side supported by pillows
Encourage coughing and deep breathing every 2 hours
36. The nurse is providing a discharge instruction about the
prevention of urinary stasis to a client with frequent bladder
infection. Which of the following will the nurse include in the
instruction?
Drink 3-4 quarts of fluid every day
Empty the bladder every 2-4 hours while awake
Encourage the use of coffee, tea, and colas for their diuretic
effect
Teach Kegel exercises to control bladder flow
37. A male client visits the clinic for check-up. The client tells
the nurse that there is a yellow discharge from his penis. He
also experiences a burning sensation when urinating. The
nurse is suspecting of gonorrhea. What teaching is necessary
for this client?
Sex partner of 3 months ago must be treated
Women with gonorrhea are symptomatic
Use a condom for sexual activity
Sex partner needs to be evaluated
38. A client with AIDS is admitted in the hospital. He is
receiving intravenous therapy. While the nurse is assessing
the IV site, the client becomes confused and restless and the
intravenous catheter becomes disconnected and minimal
amount of the client’s blood spills onto the floor. Which
action will the nurse take to remove the blood spill?
Promptly clean with a 1:10 solution of household bleach and
water
Promptly clean up the blood spill with full-strength
antimicrobial cleaning solution
Immediately mop the floor with boiling water
Allow the blood to dry before cleaning to decrease the
possibility of cross-contamination
39. Before surgery, the physician ordered pentobarbital
sodium (Nembutal) for the client to sleep. The night before
the scheduled surgery, the nurse gave the pre-medication.
One hour later the client is still unable to sleep. The nurse
review the client’s chart and note the physician’s prescription
with an order to repeat. What should the nurse do next?
Rub the client’s back until relaxed
Prepare a glass of warm milk
Give the second dose of pentobarbital sodium
Explore the client’s feelings about surgery
40. The nurse on the night shift is making rounds in the
nursing care unit. The nurse is about to enter to the client’s
room when a ventilator alarm sounds, what is the first action
the nurse should do?
Assess the lung sounds
Suction the client right away
Look at the client
Turn and position the client
41. What effective precautions should the nurse use to
control the transmission of methicillin-resistant
Staphylococcus aureus (MRSA)?
Use gloves and handwashing before and after client contact
Do nasal cultures on healthcare providers
Place the client on total isolation
Use mask and gown during care of the MRSA client
42. The postoperative gastrectomy client is scheduled for
discharge. The client asks the nurse, “When I will be allowed
to eat three meals a day like the rest of my family?”. The
appropriate nursing response is:
“You will probably have to eat six meals a day for the rest of
your life.”
“Eating six meals a day can be a bother, can’t it?”
“Some clients can tolerate three meals a day by the time they
leave the hospital. Maybe it will be a little longer for you.”
“ It varies from client to client, but generally in 6-12 months
most clients can return to their previous meal patterns”
43. A male client with cirrhosis is complaining of belly pain,
itchiness and his breasts are getting larger and also the
abdomen. The client is so upset because of the discomfort
and asks the nurse why his breast and abdomen are getting
larger. Which of the following is the appropriate nursing
response?
“How much of a difference have you noticed”
“It’s part of the swelling your body is experiencing”
“It’s probably because you have been less physically active”
“Your liver is not destroying estrogen hormones that all men
produce”
44. A client is diagnosed with detached retina and scheduled
for surgery. Preoperative teaching of the nurse to the client
includes:
No eye pain is expected postoperatively
Semi-fowler’s position will be used to reduce pressure in the
eye.
Eye patches may be used postoperatively
Return of normal vision is expected following surgery
45. A 70-year-old client is brought to the emergency
department with a caregiver. The client has manifestations of
anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
Talk to the client about the caregiver and support system
Complete a gastrointestinal and neurological assessment
Check the lab data for serum albumin, hematocrit and
hemoglobin
Complete a police report on elder abuse
46. A nurse is providing a discharge instruction to the client
about the self-catheterization at home. Which of the
following instructions would the nurse include?
Wash the catheter with soap and water after each use
Lubricate the catheter with Vaseline
Perform the Valsalva maneuver to promote insertion
Replace the catheter with a new one every 24 hour
47. The nurse in the nursing care unit is assigned to care to a
client who is Immunocompromised. The client tells the nurse
that his chest is painful and the blisters are itchy. What would
be the nursing intervention to this client?
Call the physician
Give a prn pain medication
Clarify if the client is on a new medication
Use gown and gloves while assessing the lesions
48. A client is admitted and has been diagnosed with
bacterial (meningococcal) meningitis. The infection control
registered nurse visits the staff nurse caring to the client.
What statement made by the nurse reflects an understanding
of the management of this client?
speech pattern may be altered
Respiratory isolation is necessary for 24 hours after
antibiotics are started
Perform skin culture on the macular popular rash
Expect abnormal general muscle contractions
49. A 18-year-old male client had sustained a head injury
from a motorbike accident. It is uncertain whether the client
may have minimal but permanent disability. The family is
concerned regarding the client’s difficulty accepting the
possibility of long term effects. Which nursing diagnosis is
best for this situation?
Nutrition, less than body requirements
Injury, potential for sensory-perceptual alterations
Impaired mobility, related to muscle weakness
Anticipatory grieving, due to the loss of independence
50. A client with AIDS is scheduled for discharge. The client
tells the nurse that one of his hobbies at home is gardening.
What will be the discharge instruction of the nurse to the
client knowing that the client is prone to toxoplasmosis?
Wash all vegetables before cooking
Wear gloves when gardening
Wear a mask when travelling to foreign countries
Avoid contact with cats and birds
Answers and Rationales
1. D. The Heimlich flutter valve has a one-way valve that
allows air and fluid to drain. Underwater seal drainage
is not necessary. This can be connected to a drainage
bag for the patient’s mobility. The absence of a long
drainage tubing and the presence of a one-way valve
promote effective therapy
2. C. C = the normal CVP is 0-8 mmHg. This value reflects
hypervolemia. The right ventricular function of this
client reflects fluid volume overload, and the physician
should be notified.
3. C. A hot tub bath or shower in the morning helps many
patients limber up and reduces the symptoms of early
morning stiffness. Cold and ice packs are used to a
lesser degree, though some clients state that cold
decreases localized pain, particularly during acute
attacks.
4. D. These substances stimulate the production of
hydrochloric acid, which is detrimental in peptic ulcer
disease.
5. D. The three-point gait is appropriate when weight
bearing is not allowed on the affected limb. The swing-
to and swing-through crutch gaits may also be used
when only one leg can be used for weight bearing
6. A. The client needs to be told before surgery that the
catheter causes the urge to void. Attempts to void
 around the catheter cause the bladder muscles to
contract and result in painful spasms.
7. B. Bland feedings should be given in small amounts on
a frequent basis to neutralize the hydrochloric acid and
to prevent overload
8. C. Chilling the tube before insertion assists in relieving
some of the nasal discomfort. Water-soluble lubricants
along with viscous lidocaine (Xylocaine) may also be
used. It is usually only lightly lubricated before
insertion
9. B. Whole milk should be avoided to include in the
client’s diet because it has 120 mg of sodium in 8 0z of
milk.
10. A. Alcohol is extremely drying and contributes to skin
break down. An emollient lotion should be used.
11. D. Potassium influences the excitability of nerves and
muscles. When potassium is low and the client is on
digoxin, the risk of digoxin toxicity is increased.
12. C. This position allows maximum expansion,
ventilation, and perfusion of the remaining lung.
13. A. These foods are high in potassium
14. B. Stress on the suture line should be avoided. Prevent
flexion or hyperextension of the neck, and provide a
small pillow under thehead and neck. Neck muscles
have been affected during a thyroidectomy, support
essential for comfort and incisional support.
15. A. A positive nitrogen balance is important for meeting
metabolic needs, tissue repair, and resistance to
infection. Caloric goals may be as high as 5000 calories
per day.
16. C. The best early intervention would be to increase
fluid intake, because constipation is common when
activity is decreased or usual routines have been
interrupted.
17. A. Because the client’s ability is to react to stress is
decreased, maintaining a quiet environment becomes
A nursing priority. Dehydration is a common problem
in Addison’s disease, so close observation of the
client’s hydration level is crucial. To promote optimal
hydration and sodium intake, fluid intake is increased,
particularly fluid containing electrolytes, such as
broths, carbonated beverages, and juices.
18. C. At about 48-72 hours, the client must be turned
onto the abdomen to prevent flexion contractures.
19. B. The client should not drive for 2 weeks after surgery
to avoid stress on the incision. This reflects a need for
additional teaching.
20. A. Extremes in heat and cold will exacerbate symptoms.
Heat delays transmission of impulses and increases
fatigue.
21. A. Vigilant implementation of standard precautions
and medical asepsis is an effective means of
preventing infection
22. C. Noncompliance is a major problem in the
management of chronic disease. In hypertension, the
client often does not feel ill and thus does not see a
need to follow a treatment regimen.
23. B. An accumulation of blood from the kidney into the
abdomen would manifest itself with these symptoms
24. D. Fluids liquefy secretions and therefore make it
easier to expectorate
25. D. Physical assessment guidelines recommend listening
for atleast 2 minutes in each quadrant (and up to 5
minutes, not at least 5 minutes).
26. A. Compression stockings promote venous return and
prevent peripheral pooling.
27. A. Placing food in the unaffected side of the mouth
assists in the swallowing process because the client
has sensation on that side and will have more control
over the swallowing process.
28. D. Daily weights are taken following nephrectomy.
Daily increases of 2 lb or more are indicative of fluid
retention and should be reported to the physician.
Intake and output records may also reflect this
imbalance.
29. A. Clients with cirrhosis have already coagulation due
to thrombocytopenia and vitamin K deficiency. This
could be a sign of bleeding
30. B. Exercise enhances glucose uptake, and the client is
at risk for an insulin reaction. Snacks with
carbohydrates will help.
31. C. These are symptoms of diabetes insipidus. The
patient can become hypovolemic and vasopressin may
reverse the Polyuria.
32. D. Peripheral neuropathy refers to nerve damage of
the hands and feet. The client did not notice that the
object pierced the skin.
33. A. The elevation of the stump on a pillow for the first
24 hours decreases edema and increases venous return.
34. B. The priority is to maintain client’s safety. With
syncope and vertigo, the client is at high risk for falling.
35. D. Coughing and deep breathing are essential for re-
expansion of the lung
36. B. Avoiding stasis of urine by emptying the bladder
every 2-4 hours will prevent overdistention of the
bladder and future urinary tract infections.
37. D. If infected, the sex partner must be evaluated and
treated
38. A. A 1:10 solution of household bleach and water is
recommended by the Centers for Disease Control and
Prevention to kill the human immunodeficiency virus
(HIV).
39. D. Given the data, presurgical anxiety is suspected. The
client needs an opportunity to talk about concerns
related to surgery before further actions (which may
mask the anxiety).
40. C. A quick look at the client can help identify the type
and cause of the ventilator alarm. Disconnection of the
tube from the ventilator, bronchospasm, and anxiety
are some of the obvious reasons that could trigger an
alarm.
41. A. Contact isolation has been advised by the Centers
for Disease Control and Prevention (CDC) to control
transmission of MRSA, which includes gloves and
handwashing.
42. D. In response to the question of the client, the nurse
needs to provide brief, accurate information. Some
clients who have had gastrectomies are able to
tolerate three meals a day before discharge from the
hospital. However, for the majority of clients, it takes
6-12 months before their surgically reduced stomach
has stretched enough to accommodate a larger meal.
43. A. This allows the client to elaborate his concern and
provides the nurse a baseline of assessment
44. C. Use of eye patches may be continued
postoperatively, depending on surgeon preference.
This is done to achieve >90% success rate of the
surgery.
45. B. Assessment and more data collection are needed.
The client may have gastrointestinal or neurological
problems that account for the symptoms. The anorexia
could result from medications, poor dentition, or
indigestion, the bruises may be attributed to ataxia,
frequent falls, vertigo, or medication.
46. A. The catheter should be washed with soap and water
after withdrawal and placed in a clean container. It can
be reused until it is too hard or too soft for insertion.
Self-care, prevention of complications, and cost-
effectiveness are important in home management.
47. D. The client may have herpes zoster (shingles), a viral
infection. The nurse should use standard precautions
in assessing the lesions. Immunocompromised clients
are at risk for infection.
48. B. After a minimum of 24 hours of IV antibiotics, the
client is no longer considered communicable.
Evaluation of the nurse’s knowledge is needed for safe
care and continuity of care.
49. D. Stem of the question supports this choice by stating
that the client has difficulty accepting the potential
disability.
50. B. Toxoplasmosis is an opportunistic infection and a
parasite of birds and mammals. The oocysts remain
infectious in moist soil for about 1 year.
PNLE IV Nursing Practice
The scope of this Nursing Test IV is parallel to the NP4 NLE
Coverage:
Medical Surgical Nursing
1. Following spinal injury, the nurse should encourage the
client to drink fluids to avoid:
Urinary tract infection.
Fluid and electrolyte imbalance.
Dehydration.
Skin breakdown.
2. The client is transferred from the operating room to
recovery room after an open-heart surgery. The nurse
assigned is taking the vital signs of the client. The nurse
notified the physician when the temperature of the client
rises to 38.8 ºC or 102 ºF because elevated temperatures:
May be a forerunner of hemorrhage.
Are related to diaphoresis and possible chilling.
May indicate cerebral edema.
Increase the cardiac output.
3. After radiation therapy for cancer of the prostate, the
client experienced irritation in the bladder. Which of the
following sign of bladder irritability is correct?
Hematuria
Dysuria
Polyuria
Dribbling
4. A client is diagnosed with a brain tumor in the occipital
lobe. Which of the following will the client most likely
experience?
Visual hallucinations.
Receptive aphasia.
Hemiparesis.
Personality changes.
5. A client with Addison’s disease has a blood pressure of
65/60. The nurse understands that decreased blood pressure
of the client with Addison’s disease involves a disturbance in
the production of:
Androgens
Glucocorticoids
Mineralocorticoids
Estrogen
6. The nurse is planning to teach the client about a
spontaneous pneumothorax. The nurse would base the
teaching on the understanding that:
Inspired air will move from the lung into the pleural space.
There is greater negative pressure within the chest cavity.
The heart and great vessels shift to the affected side.
The other lung will collapse if not treated immediately.
7. During an assessment, the nurse recognizes that the client
has an increased risk for developing cancer of the tongue.
Which of the following health history will be a concern?
Heavy consumption of alcohol.
Frequent gum chewing.
Nail biting.
Poor dental habits.
8. The client in the orthopedic unit asks the nurse the reason
behind why compact bone is stronger than cancellous bone.
Which of the following is the correct response of the nurse?
Compact bone is stronger than cancellous bone because of
its greater size.
Compact bone is stronger than cancellous bone because of
its greater weight.
Compact bone is stronger than cancellous bone because of
its greater volume.
Compact bone is stronger than cancellous bone because of
its greater density.
9. The nurse is reviewing the laboratory results of the client.
In reviewing the results of the RBC count, the nurse
understands that the higher the red blood cell count, the :
Greater the blood viscosity.
Higher the blood pH.
Less it contributes to immunity.
Lower the hematocrit.
10. The physician advised the client with Hemiparesis to use a
cane. The client asks the nurse why cane will be needed. The
nurse explains to the client that cane is advised specifically to:
Aid in controlling involuntary muscle movements.
Relieve pressure on weight-bearing joints.
Maintain balance and improve stability.
Prevent further injury to weakened muscles.
11. The nurse is conducting a discharge teaching regarding
the prevention of further problems to a client who
undergone surgery for carpal tunnel syndrome of the right
hand. Which of the following instruction will the nurse
includes?

Learn to type using your left hand only.
Avoid typing in a long period of time.
Avoid carrying heavy things using the right hand.
Do manual stretching exercise during breaks.
12. A female client is admitted because of recurrent urinary
tract infections. The client asks the nurse why she is prone to
this disease. The nurse states that the client is most
susceptible because of:
Continuity of the mucous membrane.
Inadequate fluid intake.
The length of the urethra.
Poor hygienic practices.
13. A 55-year-old client is admitted with chest pain that
radiates to the neck, jaw and shoulders that occurs at rest,
with high body temperature, weak with generalized sweating
and with decreased blood pressure. A myocardial infarction is
diagnosed. The nurse knows that the most accurate
explanation for one of these presenting adaptations is:
Catecholamines released at the site of the infarction causes
intermittent localized pain.
Parasympathetic reflexes from the infarcted myocardium
causes diaphoresis.
Constriction of central and peripheral blood vessels causes a
decrease in blood pressure.
Inflammation in the myocardium causes a rise in the systemic
body temperature.
14. Following an amputation of a lower limb to a male client,
the nurse provides an instruction on how to prevent a hip
flexion contracture. The nurse should instruct the client to:.
Perform quadriceps muscle setting exercises twice a day.
Sit in a chair for 30 minutes three times a day.
Lie on the abdomen 30 minutes every four hours.
Turn from side to side every 2 hours.
15. The physician scheduled the client with rheumatoid
arthritis for the injection of hydrocortisone into the knee
joint. The client asks the nurse why there is a need for this
injection. The nurse explains that the most important reason
for doing this is to:
Lubricate the joint.
Prevent ankylosis of the joint.
Reduce inflammation.
Provide physiotherapy.
16. The nurse is assigned to care for a 57-year-old female
client who had a cataract surgery an hour ago. The nurse
should:
Advise the client to refrain from vigorous brushing of teeth
and hair.
Instruct the client to avoid driving for 2 weeks.
Encourage eye exercises to strengthen the ocular
musculature.
Teach the client coughing and deep-breathing techniques.
17. A client with AIDS develops bacterial pneumonia is
admitted in the emergency department. The client’s arterial
blood gases is drawn and the result is PaO2 80mmHg. then
arterial blood gases are drawn again and the level is reduced
from 80 mmHg to 65 mmHg. The nurse should;
Have arterial blood gases performed again to check for
accuracy.
Increase the oxygen flow rate.
Notify the physician.
Decrease the tension of oxygen in the plasma.
18. An 18-year-old college student is brought to the
emergency department due to serious motor vehicle
accident. Right above-knee-amputation is done. Upon
awakening from surgery the client tells the nurse, “What
happened to me? I cannot remember anything?” Which of
the following would be the appropriate initial nursing
response?
“You sound concerned; You’ll probably remember more as
you wake up.”
“Tell me what you think happened.”
“You were in a car accident this morning.”
“An amputation of your right leg was necessary because of
an accident.”
19. A 38-year-old client with severe hypertension is
hospitalized. The physician prescribed a Captopril (Capoten)
and Alprazolam (Xanax) for treatment. The client tells the
nurse that there is something wrong with the medication and
nursing care. The nurse recognizes this behavior is probably a
manifestation of the client’s:
Reaction to hypertensive medications.
Denial of illness.
Response to cerebral anoxia.
Fear of the health problem.
20. Before discharge, the nurse scheduled the client who had
a colostomy for colorectal cancer for discharge instruction
about resuming activities. The nurse should plan to help the
client understands that:
After surgery, changes in activities must be made to
accommodate for the physiologic changes caused by the
operation.
Most sports activities, except for swimming, can be resumed
based on the client’s overall physical condition.
With counseling and medical guidance, a near normal
lifestyle, including complete sexual function is possible.
Activities of daily living should be resumed as quickly as
possible to avoid depression and further dependency.
21. A client is scheduled for bariatric surgery. Preoperative
teaching is done. Which of the following statement would
alert the nurse that further teaching to the client is necessary?
“I will be limiting my intake to 600 to 800 calories a day once
I start eating again.”
“I’m going to have a figure like a model in about a year.”
“I need to eat more high-protein foods.”
“I will be going to be out of bed and sitting in a chair the first
day after surgery.”.
22. The client who had transverse colostomy asks the nurse
about the possible effect of the surgery on future sexual
relationship. What would be the best nursing response?
The surgery will temporarily decrease the client’s sexual
impulses.
Sexual relationships must be curtailed for several weeks.
The partner should be told about the surgery before any
sexual activity.
The client will be able to resume normal sexual relationships.
23. A 75-year-old male client tells the nurse that his wife has
osteoporosis and asks what chances he had of getting also
osteoporosis like his wife. Which of the following is the
correct response of the nurse?
“This is only a problem for women.”
“You are not at risk because of your small frame.”
“You might think about having a bone density test,”
“Exercise is a good way to prevent this problem.”
24. An older adult client with acute pain is admitted in the
hospital. The nurse understands that in managing acute pain
of the client during the first 24 hours, the nurse should
ensure that:
Ordered PRN analgesics are administered on a scheduled
basis.
Patient controlled analgesia is avoided in this population.
Pain medication is ordered via the intramuscular route.
An order for meperidine (Demerol) is secured for pain relief.
25. A nurse is caring to an older adult with presbycusis. In
formulating nursing care plan for this client, the nurse should
expect that hearing loss of the client that is caused by aging
to have:
Overgrowth of the epithelial auditory lining.
Copious, moist cerumen.
Difficulty hearing women’s voices.
Tears in the tympanic membrane.
26. The nurse is reviewing the client’s chart about the
ordered medication. The nurse must observe for signs of
hyperkalemia when administering:
Furosemide (Lasix)
Hydrochlorothiazide (HydroDIURIL)
Metolazone (Zaroxolyn)
Spironolactone (Aldactone)
27. The physician prescribed Albuterol (Proventil) to the
client with severe asthma. After the administration of the
medication the nurse should monitor the client for:
Palpitation
Visual disturbance
Decreased pulse rate
Lethargy
28. A client is receiving diltiazem (Cardizem). What should
the nurse include in a teaching plan aimed at reducing the
side effects of this medication?
Take the drug with an antacid.
Lie down after meals.
Avoid dairy products in diet.
Change positions slowly.
29. A client is receiving simvastatin (Zocor). The nurse is
aware that this medication is effective when there is
decrease in:
The triglycerides
The INR
Chest pain
Blood pressure
30. A client is taking nitroglycerine tablets, the nurse should
teach the client the importance of:
Increasing the number of tablets if dizziness or hypertension
occurs.
Limiting the number of tablets to 4 per day.
Making certain the medication is stored in a dark container.
Discontinuing the medication if a headache develops.
31. The physician prescribes Ibuprofen (Motrin) and
hydroxychloroquine sulfate (Plaquenil) for a 58-year-old male
client with arthritis. The nurse provides information about
toxicity of the hydroxychloroquine. The nurse can determine
if the information is clearly understood if the client states:
“I will contact the physician immediately if I develop blurred
vision.”
“I will contact the physician immediately if I develop urinary
retention.”
“I will contact the physician immediately if I develop
swallowing difficulty.”
“I will contact the physician immediately if I develop feelings
of irritability.”
32. The client with an acute myocardial infarction is
hospitalized for almost one week. The client experiences
nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
Adverse effects of spironolactone (Aldactone)
Adverse effects of digoxin (Lanoxin)
Therapeutic effects of propranolol (Indiral)
Therapeutic effects of furosemide (Lasix)
33. A client with a partial occlusion of the left common
carotid artery is scheduled for discharge. The client is still
receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of
Coumadin. The nurse should tell the client to consult with the
physician if:
Swelling of the ankles increases.
Blood appears in the urine.
Increased transient Ischemic attacks occur.
The ability to concentrate diminishes.
34. Levodopa is ordered for a client with Parkinson’s disease.
Before starting the medication, the nurse should know that:
Levodopa is inadequately absorbed if given with meals.
Levodopa may cause the side effects of orthostatic
hypotension.
Levodopa must be monitored by weekly laboratory tests.
Levodopa causes an initial euphoria followed by depression.
35. In making a diagnosis of myasthenia gravis Edrophonium
HCI (Tensilon) is used. The nurse knows that this drug will
cause a temporary increase in:
Muscle strength
Symptoms
Blood pressure
Consciousness
36. The nurse can determine the effectiveness of
carbamazepine (Tegretol) in the management of trigeminal
neuralgia by monitoring the client’s:
Seizure activity
Liver function
Cardiac output
Pain relief
37. Administration of potassium iodide solution is ordered to
the client who will undergo a subtotal thyroidectomy. The
nurse understands that this medication is given to:
Ablate the cells of the thyroid gland that produce T4.
Decrease the total basal metabolic rate.
Decrease the size and vascularity of the thyroid.
Maintain function of the parathyroid gland.
38. A client with Addison’s disease is scheduled for discharge.
Before the discharge, the physician prescribes hydrocortisone
and fludrocortisone. The nurse expects the hydrocortisone to:
Increase amounts of angiotensin II to raise the client’s blood
pressure.
Control excessive loss of potassium salts.
Prevent hypoglycemia and permit the client to respond to
stress.
Decrease cardiac dysrhythmias and dyspnea.
39. A client with diabetes insipidus is taking Desmopressin
acetate (DDAVP). To determine if the drug is effective, the
nurse should monitor the client’s:
Arterial blood pH
Pulse rate
Serum glucose
Intake and output
40. A client with recurrent urinary tract infections is to be
discharged. The client will be taking nitrofurantoin (Macrobid)
50 mg po every evening at home. The nurse provides
discharge instructions to the client. Which of the following
instructions will be correct?
Strain urine for crystals and stones
Increase fluid intake.
Stop the drug if the urinary output increases
Maintain the exact time schedule for drug taking.
41. A client with cancer of the lung is receiving chemotherapy.
The physician orders antibiotic therapy for the client. The
nurse understands that chemotherapy destroys rapidly
growing leukocytes in the:
Bone marrow
Liver
Lymph nodes
Blood
42. The physician reduced the client’s Dexamethasone
(Decadron) dosage gradually and to continue a lower
maintenance dosage. The client asks the nurse about the
change of dosage. The nurse explains to the client that the
purpose of gradual dosage reduction is to allow:
Return of cortisone production by the adrenal glands.
Production of antibodies by the immune system
Building of glycogen and protein stores in liver and muscle
Time to observe for return of increases intracranial pressure
43. The nurse is assigned to care for a client with diarrhea.
Excessive fluid loss is expected. The nurse is aware that fluid
deficit can most accurately be assessed by:
The presence of dry skin
A change in body weight
An altered general appearance
A decrease in blood pressure
44. Which of the following is the most important electrolyte
of intracellular fluid?
Potassium
Sodium
Chloride
Calcium
45. Which of the following client has a high risk for
developing hyperkalemia?
Crohn’s disease
End-Stage renal disease
Cushing’s syndrome
Chronic heart failure
46. The nurse is reviewing the laboratory result of the client.
The client’s serum potassium level is 5.8 mEq/L. Which of the
following is the initial nursing action?
Call the cardiac arrest team to alert them
Call the laboratory and repeat the test
Take the client’s vital signs and notify the physician
Obtain an ECG strip and have lidocaine available
47. Potassium chloride, 20 mEq, is ordered and to be added
in the IV solution of a client in a diabetic ketoacidosis. The
primary reason for administering this drug is:
Replacement of excessive losses
Treatment of hyperpnea
Prevention of flaccid paralysis
Treatment of cardiac dysrhythmias
48. A female client is brought to the emergency unit. The
client is complaining of abdominal cramps. On assessment,
client is experiencing anorexia and weight is reduced. The
physician’s diagnosis is colitis. Which of the following
symptoms of fluid and electrolyte imbalance should the
nurse report immediately?
Skin rash, diarrhea, and diplopia
Development of tetaniy with muscles spasms
Extreme muscle weakness and tachycardia
Nausea, vomiting, and leg and stomach cramps.
49. The client is to receive an IV piggyback medication. When
preparing the medication the nurse should be aware that it is
very important to:
Use strict sterile technique
Use exactly 100mL of fluid to mix the medication
Change the needle just before adding the medication
Rotate the bag after adding the medication
50. The nurse is reviewing the laboratory result of the client.
An arterial blood gas report indicates the client’s pH is 7.20,
PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are
consistent with:
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Answers and Rationales
1. A. Clients in the early stage of spinal cord damage
experience an atonic bladder, which is characterized by
 the absence of muscle tone, an enlarged capacity, no
feeling of discomfort with distention, and overflow
with a large residual. This leads to urinary stasis and
infection. High fluid intake limits urinary stasis and
infection by diluting the urine and increasing urinary
output.
2. D. The temperature of 102 ºF (38.8ºC) or greater lead
to an increased metabolism and cardiac workload.
3. B. Dysuria, nocturia, and urgency are all signs an
irritable bladder after radiation therapy.
4. A. The occipital lobe is involve with visual
interpretation.
5. C. Mineralocorticoids such as aldosterone cause the
kidneys to retain sodium ions. With sodium, water is
also retained, elevating blood pressure. Absence of
this hormone thus causes hypotension.
6. B. As a person with a tear in the lung inhales, air
moves through that opening into the intrapleural and
causes partial or complete collapse of the lungs.
7. A. Heavy alcohol ingestion predisposes an individual to
the development of oral cancer.
8. D. The greater the density of compact bone makes it
stronger than the cancellous bone. Compact bone
forms from cancellous bone by the addition of
concentric rings of bones substances to the marrow
spaces of cancellous bone. The large marrow spaces
are reduced to haversian canals.
9. A. Viscosity, a measure of a fluid’s internal resistance
to flow, is increased as the number of red cells
suspended in plasma.
10. C. Hemiparesis creates instability. Using a cane
provides a wider base of support and, therefore
greater stability.
11. D. Manual stretching exercises will assist in keeping
the muscles and tendons supple and pliable, reducing
the traumatic consequences of repetitive activity.
12. C. The length of the urethra is shorter in females than
in males; therefore microorganisms have a shorter
distance to travel to reach the bladder. The proximity
of the meatus to the anus in females also increases this
incidence.
13. D. Temperature may increase within the first 24 hours
and persist as long as a week.
14. C. The hips are in extension when the client is prone;
this keeps the hips from flexing.
15. C. Steroids have an anti-inflammatory effect that can
reduce arthritic pannus formation.
16. A. Activities such as rigorous brushing of hair and teeth
cause increased intraocular pressure and may lead to
hemorrhage in the anterior chamber.
17. C. This decrease in PaO2 indicates respiratory failure; it
warrants immediate medical evaluation.
18. C. This is truthful and provides basic information that
may prompt recollection of what happened; it is a
starting point.
19. D. Clients adapting to illness frequently feel afraid and
helpless and strike out at health team members as a
way of maintaining control or denying their fear.
20. C. There are few physical restraints on activity
postoperatively, but the client may have emotional
problems resulting from the body image changes.
21. B. Clients need to be prepared emotionally for the
body image changes that occur after bariatric surgery.
Clients generally experience excessive abdominal skin
folds after weight stabilizes, which may require a
panniculectomy. Body image disturbance often occurs
in response to incorrectly estimating one’s size; it is
not uncommon for the client to still feel fat no matter
how much weight is lost.
22. D. Surgery on the bowel has no direct anatomic or
physiologic effect on sexual performance. However,
the nurse should encourage verbalization.
23. C. Osteoporosis is not restricted to women; it is a
potential major health problem of all older adults;
estimates indicate that half of all women have at least
one osteoporitic fracture and the risk in men is
estimated between 13% and 25%; a bone mineral
density measurement assesses the mass of bone per
unit volume or how tightly the bone is packed.
24. A. Around-the-clock administration of analgesics is
recommended for acute pain in the older adult
population; this help to maintain a therapeutic blood
level of pain medication.
25. C. Generally, female voices have a higher pitch than
male voices; older adults with presbycusis (hearing loss
caused by the aging process) have more difficulty
hearing higher-pitched sounds.
26. D. Aldactone is a potassium-sparing diuretic;
hyperkalemia is an adverse effect.
27. A. Albuterol’s sympathomimetic effect causes cardiac
stimulation that may cause tachycardia and palpitation.
28. D. Changing positions slowly will help prevent the side
effect of orthostatic hypotension.
29. A. Therapeutic effects of simvastatin include decreased
serum triglyceries, LDL and cholesterol.
30. C. Nitroglycerine is sensitive to light and moisture ad
must be stored in a dark, airtight container.
31. A. Visual disturbance are a sign of toxicity because
retinopathy can occur with this drug.
32. B. Toxic levels of Lanoxin stimulate the medullary
chemoreceptor trigger zone, resulting in nausea and
subsequent anorexia.
33. B. Warfarin derivatives cause an increase in the
prothrombin time and INR, leading to an increased risk
for bleeding. Any abnormal or excessive bleeding must
be reported, because it may indicate toxic levels of the
drug.
34. B. Levodopa is the metabolic precursor of dopamine. It
reduces sympathetic outflow by limiting
vasoconstriction, which may result in orthostatic
hypotension.
35. A. Tensilon, an anticholinesterase drug, causes
temporary relief of symptoms of myasthenia gravis in
client who have the disease and is therefore an
effective diagnostic aid.
36. D. Carbamazepine ( Tegretol) is administered to
control pain by reducing the transmission of nerve
impulses in clients with trigeminal neuralgia.
37. C. Potassium iodide, which aids in decreasing the
vascularity of the thyroid gland, decreases the risk for
hemorrhage.
38. C. Hydrocortisone is a glucocorticoid that has anti-
inflammatory action and aids in metabolism of
carbohydrate, fat, and protein, causing elevation of
blood glucose. Thus it enables the body to adapt to
stress.
39. D. DDAVP replaces the ADH, facilitating reabsorption
of water and consequent return of normal urine
output and thirst.
40. B. To prevent crystal formation, the client should have
sufficient intake to produce 1000 to 1500 mL of urine
daily while taking this drug.
41. A. Prolonged chemotherapy may slow the production
of leukocytes in bone marrow, thus suppressing the
activity of the immune system. Antibiotics may be
required to help counter infections that the body can
no longer handle easily.
42. A. Any hormone normally produced by the body must
be withdrawn slowly to allow the appropriate organ to
adjust and resume production.
43. B. Dehydration is most readily and accurately
measured by serial assessment of body weight; 1 L of
fluid weighs 2.2 pounds.
44. A. The concentration of potassium is greater inside the
cell and is important in establishing a membrane
potential, a critical factor in the cell’s ability to
function.
45. B. The kidneys normally eliminate potassium from the
body; hyperkalemia may necessitate dialysis.
46. C. Vital signs monitor cardiorespiratory status;
hyperkalemia causes serious cardiac dysrhythmias.
47. A. Once treatment with insulin for diabetic
ketoacidosis is begun, potassium ions reenter the cell,
causing hypokalemia; therefore potassium, along with
the replacement fluid, is generally supplied.
48. C. Potassium, the major intracellular cation, functions
with sodium and calcium to regulate neuromuscular
activity and contraction of muscle fibers, particularly
the heart muscle. In hypokalemia these symptoms
develop.
49. A. Because IV solutions enter the body’s internal
environment, all solutions and medications utilizing
this route must be sterile to prevent the introduction
of microbes.
50. A. A low pH and bicarbonate level are consistent with
metabolic acidosis.
PNLE V Nursing Practice
The scope of this Nursing Test V is parallel to the NP5 NLE
Coverage:
Psychiatric Nursing
1. A 17-year-old client has a record of being absent in the
class without permission, and “borrowing” other people’s
things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the
items, there is no problem to use it by other people. It is
important for the nurse to understand that
psychodynamically, the behavior of the client may be largely
attributed to a development defect related to the:
Oedipal complex
Superego
Id
Ego
2. A client tells the nurse, “Yesterday, I was planning to kill
myself.” What is the best nursing response to this cient?
“What are you going to do this time?”
Say nothing. Wait for the client’s next comment
“You seem upset. I am going to be here with you; perhaps
you will want to talk about it”
“Have you felt this way before?”
3. In crisis intervention therapy, which of the following
principle that the nurse will use to plan her/his goals?
Crises are related to deep, underlying problems
Crises seldom occur in normal people’s lives
Crises may go on indefinitely.
Crises usually resolved in 4-6 weeks.
4. The nurse enters the room of the male client and found
out that the client urinates on the floor. The client hides
when the nurse is about to talk to him. Which of the
following is the best nursing intervention?
Place restriction on the client’s activities when his behavior
occurs.
Ask the client to clean the soiled floor.
Take the client to the bathroom at regular intervals.
Limit fluid intake.
5. A young lady with a diagnosis of schizophrenic reaction is
admitted to the psychiatric unit. In the past two months, the
client has poor appetite, experienced difficulty in sleeping,
was mute for long periods of time, just stayed in her room,
grinning and pointing at things. What would be the initial
nursing action on admitting the client to the unit?
Assure the client that “ You will be well cared for.”
Introduce the client to some of the other clients.
Ask “Do you know where you are?”
Take the client to the assigned room.
6. A 16-year-old girl was diagnosed with anorexia. What
would be the first assessment of the nurse?
What food she likes.
Her desired weight.
Her body image.
What causes her behavior.
7. On an adolescent unit, a nurse caring to a client was
informed that her client’s closest roommate dies at night.
What would be the most appropriate nursing action?
Do not bring it up unless the client asks.
Tell the client that her roommate went home.
Tell the client, if asked, “You should ask the doctor.”
Tell the client that her closest roommate died.
8. A woman gave birth to an unhealthy infant, and with some
body defects. The nurse should expect the woman’s initial
reactions to include:
Depression
Withdrawal
Apathy
Anger
9. A client in the psychiatric unit is shouting out loud and tells
the nurse, “Please, help me. They are coming to get me.”
What would be the appropriate nursing response?
“ I won’t let anyone get you.”
“Who are they?”
“I don’t see anyone coming.”
“You look frightened.”
10. A client who is severely obese tells the nurse, “My
therapist told me that I eat a lot because I didn’t get any
attention and love from my mother. What does the therapist
mean?” What is the best nursing response?
“What do you think is the connection between your not
getting enough love and overeating?”
“Tell me what you think the therapist means.”
“You need to ask your therapist.”
“ We are here to deal with your diet, not with your
psychological problems.”
11. After the discussion about the procedure the physician
scheduled the client for mastectomy. The client tells the
nurse, “If my breasts will be removed, I’m afraid my husband
will not love me anymore and maybe he will never touch me.”
What should the nurse’s response?
“I doubt that he feels that way.”
“What makes you feel that way?”
“Have you discussed your feelings with your husband?”
Ask the husband, in front of the wife, how he feels about this.
12. The child is brought to the hospital by the parents. During
assessment of the nurse, what parental behavior toward a
child should alert the nurse to suspect child abuse?
Ignoring the child.
Flat affect.
Expressions of guilt.
Acting overly solicitous toward the child
13. A nurse is caring to a client with manic disorder in the
psychiatric ward. On the morning shift, the nurse is talking
with the client who is now exhibiting a manic episode with
flight of ideas. The nurse primarily needs to:
Focus on the feelings conveyed rather than the thoughts
expressed.
Speak loudly and rapidly to keep the client’s attention,
because the client is easily distracted.
Allow the client to talk freely.
Encourage the client to complete one thought at a time.
14. The nurse is caring to an autistic child. Which of the
following play behavior would the nurse expect to see in a
child?
competitive play
nonverbal play
cooperative play
solitary play
15. The client is telling the nurse in the psychiatric ward, “I
hate them.” Which of the following is the most appropriate
nursing response to the client?
“Tell me about your hate.”
“I will stay with you as long as you feel this way.”
“For whom do you have these feelings?”
“I understand how you can feel this way.”
16. The mother visits her son with major depression in the
psychiatric unit. After the conversation of the client and the
mother, the nurse asks the mother how it is talking to her
son. The mother tells the nurse that it was a stressful time.
During an interview with the client, the client says, “we had a
marvelous visit.” Which of the following coping mechanism
can be described to thestatement of the client?
Identification.
Rationalization.
Denial.
Compensation.
17. A male client is quiet when the physician told him that he
has stage IV cancer and has 4 months to live. The nurse
determines that this reaction may be an example of:
Indifference
Denial
Resignation
Anger
18. A nurse is caring to a female client with five young
children. The family member told the client that her ex-
husband has died 2 days ago. The reaction of the client is
stunned silence, followed by anger that the ex-husband left
no insurance money for their young children. The nurse
should understand that:
The children and the injustice done to them by their father’s
death are the woman’s main concern.
To explain the woman’s reaction, the nurse needs more
information about the relationship and breakup.
The woman is not reacting normally to the news.
The woman is experiencing a normal bereavement reaction.
19. A client who is manic comes to the outpatient
department. The nurse is assigning an activity for the client.
What activity is best for the nurse to encourage for a client in
a manic phase?
Solitary activity, such as walking with the nurse, to decrease
stimulation.
Competitive activity, such as bingo, to increase the client’s
self-esteem.
Group activity, such as basketball, to decrease isolation.
Intellectual activity, such as scrabble, to increase
concentration.
20. The nurse is about to administer Imipramine HCI (Tofranil)
to the client, the client says, “Why should I take this?” The
doctor started me on this 10days ago; it didn’t help me at all.”
Which of the following is the best nursing response:
“What were you expecting to happen?”
“It usually takes 2-3 weeks to be effective.”
“Do you want to refuse this medication? You have the right.”
“That’s a long time wait when you feel so depressed.”
21. Which of the following drugs the nurse should choose to
administer to a client to prevent pseudoparkinsonism?
Isocarboxazid (Marplan)
Chlorpromazine HCI (Thorazine)
Trihexyphenidyl HCI (Artane)
Trifluoperazine HCI (Stelazine)
22. The nurse is caring to an 80-year-old client with dementia?
What is the most important psychosocial need for this client?
Focus on the there-and-then rather the here-and-now.
Limit in the number of visitors, to minimize confusion.
Variety in their daily life, to decrease depression.
A structured environment, to minimize regressive behaviors.
23. A client tells the nurse, “I don’t want to eat any meals
offered in this hospital because the food is poisoned.” The
nurse is aware that the client is expressing an example of:
Delusion.
Hallucination.
Negativism.
Illusion.
24. A client is admitted in the hospital. On assessment, the
nurse found out that the client had several suicidal attempts.
Which of the following is the most important nursing action?
Ignore the client as long as he or she is talking about suicide,
because suicide attempt is unlikely.
Administer medication.
Relax vigilance when the client seems to be recovering from
depression.
Maintain constant awareness of the client’s whereabouts.
25. The nurse suspects that the client is suffering from
depression. During assessment, what are the most
characteristic signs and symptoms of depression the nurse
would note?
Constipation, increased appetite.
Anorexia, insomnia.
Diarrhea, anger.
Verbosity, increased social interaction.
26. The client in the psychiatric unit states that, “The goodas
are coming! I must be ready.” In response to this neologism,
the nurse’s initial response is to:
Acknowledge that the word has some special meaning for the
client.
Try to interpret what the client means.
Divert the client’s attention to an aspect of reality.
State that what the client is saying has not been understood
and then divert attention to something that is really bound.
27. A male client diagnosed with depression tells the nurse, “I
don’t want to look weak and I don’t even cry because my
wife and my kids can’t bear it.” The nurse understands that
this is an example of:
Repression.
Suppression.
Undoing.
Rationalization.
28. A female client tells the nurse that she is afraid to go out
from her room because she thinks that the other client might
kill her. The nurse is aware that this behavior is related to:
Hallucination.
Ideas of reference.
Delusion of persecution.
Illusion.
29. A female client is taking Imipramine HCI (Tofranil) for
almost 1 week and shows less awareness of the physical body.
What problem would the nurse be most concerned?
Nausea.
Gait disturbances.
Bowel movements.
Voiding.
30. A 6-year-old client dies in the nursing unit. The parents
want to see the child. What is the most appropriate nursing
action?
Give the parents time alone with the body.
Ask the physician for permission.
Complete the postmortem care and quietly accompany the
family to the child’s room.
Suggest the parents to wait until the funeral service to say
“good-bye.”
31. A 20-year-old female client is diagnosed with anxiety
disorder. The physician prescribed Flouxetine (Prozac). What
is the most important side effects should a nurse be
concerned?
Tremor, drowsiness.
Seizures, suicidal tendencies.
Visual disturbance, headache.
Excessive diaphoresis, diarrhea.
32. A nurse is assigned to activate a client who is withdrawn,
hears voices and negativistic. What would be the best nursing
approach?
Mention that the “voices” would want the client to
participate.
Demand that the client must join a group activity.
Give the client a long explanation of the benefits of activity.
Tell the client that the nurse needs a partner for an activity.
33. A nurse is going to give a rectal suppository as a
preoperative medication to a 4-year-old boy. The boy is very
anxious and frightened. Which of the following statement by
the nurse would be most appropriate to gain the child’s
cooperation?
“Be a big kid! Everyone’s waiting for you.”
“Lie still now and I’ll let you have one of your presents before
you even have your operation.”
“Take a nice, big, deep breath and then let me hear you
count to five.”
“You look so scared. Want to know a secret? This won’t hurt
a bit!”
34. A depressed client is on an MAO inhibitor? What should
the nurse watch out for?
Hypertensive crisis.
Diet restrictions.
Taking medication with meals.
Exposure to sunlight.
35. A 16-year-old girl is admitted for treatment of a fracture.
The client shares to the nurse caring to her that her step-
father has made sexual advances to her. She got the chance
to tell it to her mother but refuses to believe. What is the
most therapeutic action of the nurse would be:
Tell the client to work it out with her father.
Tell the client to discuss it with her mother.
Ask the father about it.
Ask the mother what she thinks.
36. A client with a diagnosis of paranoid disorder is admitted
in the psychiatric hospital. The client tells the nurse, “the FBI
is following me. These people are plotting against me.” With
this statement the nurse will need to:
Acknowledge that this is the client’s belief but not the nurse’s
belief.
Ask how that makes the client feel.
Show the client that no one is behind.
Use logic to help the client doubt this belief.
37. A nurse is completing the routine physical examination to
a healthy 16-year-old male client. The client shares to the
nurse that he feels like killing his girlfriend because he found
out that her girlfriend had another boyfriend. He then laughs,
and asks the nurse to keep this a secret just between the two
of them. The nurse reviews his chart and notes that there is
no previously history of violence or psychiatric illness. Which
of the following would be the best action of the nurse to take
at this time?
Suggest the teen meet with a counselor to discuss his feelings
about his girlfriend.
Tell the teen that his feelings are normal, and recommend
that he find another girlfriend to take his mind off the
problem.
Recall the teenage boys often say things they really do not
mean and ignore the comment.
Regard the comment seriously and notify the teen’s primary
health care provider and parents
38. Which of the following person will be at highest risk for
suicide?
A student at exam time
A married woman, age 40, with 6 children.
A person who is an alcoholic.
A person who made a previous suicide attempt.
39. A male client is repetitively doing the handwashing every
time he touches things. It is important for a nurse to
understand that the client’s behavior is probably an attempt
to:
Seek attention from the staff.
Control unacceptable impulses or feelings.
Do what the voices the patient hears tell him or her to do.
Punish himself or herself for guilt feeling.
40. In a mental health settings, the basic goal of nursing is to:
Advance the science of psychiatry by initiating research and
gathering data for current statistics on emotional illness.
Plan activity programs for clients.
Understand various types of family therapy and psychological
tests and how to interpret them.
Maintain a therapeutic environment.
41. A 3-year-old boy is brought to the emergency department.
After an hour, the boy dies of respiratory failure. The mother
of the boy becomes upset, shouting and abusive, saying to
the nurse, “If it had been your son, they would have done
more to save it. “What should the nurse say or do?
Touch her and tell her exactly what was done for her baby.
Allow the mother to continue her present behavior while
sitting quietly with her.
“No, all clients are given the same good care.”
“Yes, you’re probably right. Your son did not get better care.”
42. The nurse is interacting to a client with an antisocial
personality disorder. What would be the most therapeutic
approach of the nurse to an antisocial behavior?
Gratify the client’s inner needs.
Give the client opportunities to test reality.
Provide external controls.
Reinforce the client’s self-concept.
43. A 55-year-old male client tells the nurse that he needs his
glasses and hearing aid with him in the recovery room after
the surgery, or he will be upset for not granting his request.
What is the appropriate nursing response?
“Do you get upset and confused often?”
“You won’t need your glasses or hearing aid. The nurses will
take care of you.”
“I understand. You will be able to cooperate best if you know
what is going on, so I will find out how I can arrange to have
your glasses and hearing aid available to you in the recovery
room.”
I understand you might be more cooperative if you have your
aid and glasses, but that is just not possible. Rules, you know.”
44. The male client had fight with his roommates in the
psychiatric unit. The client agitated client is placed in
isolation for seclusion. The nurse knows it is essential that:
A staff member has frequent contacts with the client.
Restraints are applied.
The client is allowed to come out after 4 hours.
All the furniture is removed form the isolation room.
45. A medical representative comes to the hospital unit for
the promotion of a new product. A female client, admitted
for hysterical behavior, is found embracing him. What should
the nurse say?
“Have you considered birth control?”
“This isn’t the purpose of either of you being here.”
“I see you’ve made a new friend.”
“Think about what you are doing.”
46. A client with dementia is for discharge. The nurse is
providing a discharge instruction to the family member
regarding safety measures at home. What suggestion can the
nurse make to the family members?
Avoid stairs without banisters.
Use restraints while the client is in bed to keep him or her
from wandering off during the night.
Use restraints while the client is sitting in a chair to keep him
or her from wandering off during the day.
Provide a night-light and a big clock.
47. A 30-year-old married woman comes to the hospital for
treatment of fractures. The woman tells the nurse that she
was physically abused by her husband. The woman receives a
call from her husband telling her to get home and things will
be different. He felt sorry of what he did. What can the nurse
advise her?
“Do you think so?”
“It’s not likely.”
“What will be different?”
“I hope so, for your sake.”
48. A female client was diagnosed with breast cancer. It is
found to be stage IV, and a modified mastectomy is
performed. After the procedure, what behaviors could the
nurse expects the client to display?
Denial of the possibility of carcinoma.
Signs of grief reaction.
Relief that the operation is over.
Signs of deep depression.
49. A client is withdrawn and does not want to interact to
anybody even to the nurse. What is the best initial nursing
approach to encourage communication with this client?
Use simple questions that call for a response.
Encourage discussion of feelings.
Look through a photo album together.
Bring up neutral topics.
50. Which of the following nursing approach is most
important in a client with depression?
Deemphasizing preoccupation with elimination, nourishment,
and sleep.
Protecting against harm to others.
Providing motor outlets for aggressive, hostile feelings.
Reducing interpersonal contacts.
Answers and Rationales
1. B. This shows a weak sense of moral consciousness.
According to Freudian theory, personality disorders
stem from a weak superego.
2. C. The client needs to have his or her feelings
acknowledged, with encouragement to discuss feelings,
and be reassured about the nurse’s presence.
3. D. Part of the definition of a crisis is a time span of 4-6
weeks.
4. C. The client is most likely confused, rather than
exhibiting acting-out, hostile behavior. Frequent
toileting will allow urination in an appropriate place.
5. D. The client needs basic, simple orientation that
directly relates to the here-and-now, and does not
require verbal interaction.
6. A. Although all options may appear correct. A is the
best because it focuses on a range of possible positive
reinforcers, a basis for an effective behavior
modification program. It can lead to concrete, specific
nursing interventions right away and provides a
therapeutic use of “control” for the 16-year-old.
7. A. The nurse needs to wait and see: do not “jump the
gun”; do not assume that the client wants to know
now.
8. D. The woman is experiencing an actual loss and will
probably exhibit many of the same symptoms as a
person who has lost someone to death.
9. C. This option is an example of pointing out reality- the
nurse’s perception.
10. B. This response asks information that the nurse can
use. If the client understands the statement, the nurse
can support the therapist when focusing on connection
between food, love, and mother. If the client does not
understand thestatement, the nurse can help get
clarification from the therapist.
11. C. This option redirects the client to talk to her
husband.
12. D. This is an example of reaction formation, a coping
mechanism.
13. A. Often the verbalized ideas are jumbled, but the
underlying feelings are discernible and must be
acknowledged.
14. D. Autistic children do best with solitary play because
they typically do not interact with others in a socially
comprehensible and acceptable way.
15. A. The nurse is asking the client to clarify and further
discuss feelings.
16. C. Denial is the act of avoiding disagreeable realities by
ignoring them.
17. B. Reactions when told of a life-threatening illness
stem from Kübler-Ross’ ideas on death and dying.
Denial is a typical grief response, and usually is a first
reaction.
18. D. Shock and anger are commonly the primary initial
reactions.
19. A. This option avoids external stimuli, yet channels the
excess motor activity that is often part of the manic
phase.
20. B. The patient needs a brief, factual answer.
21. C. Trihexyphenidyl HCI (Artane) is often used to
counteract side effect of pseudoparkinsonism, which
often accompanies the use of phenothiazine, such as
chlorpromazine HCI (Thorazine or Trifluoperazine HCI
(Stelazine).
22. D. Persons with dementia needs sameness, consistency,
structure, routine, and predictability.
23. A. This is a false belief developed in response to an
emotional need.
24. D. The client must be constantly observed.
25. B. The appetite is diminished and sleeping is affected
to a client with depression.
26. A. It is important to acknowledge a statement, even if
it is not understood.
27. D. Rationalization is the process of constructing
plausible reasons for one’s responses.
28. C. The client has ideas that someone is out to kill her.
29. D. A serious side effect of Imipramine HCI (Tofranil) is
urinary retention (voiding problems)
30. A. This allows the parents/family to grieve over the
loss of the child, by going through the steps of leave
taking.
31. B. Assess for suicidal tendencies, especially during
early therapy. There is an increased risk of seizures in
debilitated client and those with a history of seizures.
32. D. The nurse helps to activate by doing something with
the client.
33. C. Preschool children commonly experience fears and
fantasies regarding invasive procedures. The nurse
should attempts to momentarily distract the child with
a simple task that can be easily accomplished while the
child remains in the side-lying position. The
suppository can be slipped into place while the child is
counting, and then the nurse can praise the child for
cooperating, while holding the buttocks together to
prevent expulsion of the suppository.
34. A. This is the more inclusive answer, although diet
restrictions (answer1) are important, their purpose is
to prevent hypertensive crisis (answer 2).
35. D. This comes closest to beginning to focus on family-
centered approach to intervene in the “conspiracy of
silence”. This is therefore the best among the options.
36. A. The nurse should neither challenge nor use logic to
dispel an irrational belief.
37. D. Any threat to the safety of oneself or other should
always be taken seriously and never disregarded by
the nurse.
38. C. The likelihood of multiple contributing factors may
make this person at higher risk for suicide. Some
factors that may exist are physical illness related to
alcoholism, emotional factors ( anxiety, guilt, remorse),
social isolation due to impaired relationships and
economic problems related to employment.
39. B. A ritual, such as compulsive handwashing, is an
attempt to allay anxiety caused by unconscious
impulses that are frightening.
40. D. This is the most neutral answer by process of
elimination.
41. B. This option allows a normal grief response (anger).
42. C. Personality disorders stem from a weak superego,
implying a lack of adequate controls.
43. C. The client will be easier to care for if he has his
hearing aid and glasses.
44. A. Frequent contacts at times of stress are important,
especially when a client is isolated.
45. B. This response is aimed at redirecting the
inappropriate behavior.
46. D. This option is best to decrease confusion and
disorientation to place and time.
47. C. This option helps the woman to think through and
elaborate on her own thoughts and prognosis.
48. B. It is mostly likely that grief would be expressed
because of object loss.
49. D. Neutral, nonthreatening topics are best in
attempting to encourage a response.
50. C. It is important to externalize the anger away from
self.