TOPE * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFI RECALLS EXA\ NURSING COMMUNITY, NOV 2023 Philippine Nurse. GENERAL INSTRUCTIONS: 1. This test questicnnaie contains 100 test questions 2. Shade only one (1) box for each question on your answer s 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examines ANK WEW ACADEMY 'RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY TION 14 ICE I NURSING amination Review ‘more boxes shaded will invalid your answer. ‘Sheet Sot 5. Write the subject ttle "NURSING PRACTICE I" on the box provider ‘Situation: Ice, a community health nurse, Isnewly assigned as the dinic manager at Brgy Cagdara-O Health Station (BHS). He is to provide nursing care to the members of the Community and to train the berangay health workers in the provision of health services. The Municipal Health Officer (MHO) supervises his activites in the barangay. 1. A mother with her child comes in to the dinic She complains that he: child, baby SC, en 18 month old mate, is coughing with no secretions for about two days. She tals the nurse that “My child is coughing. This is going on for two days. Can I ask for Cotrimoxazole?” The nurse's best response for this stuation is: a. "This s not permissible because I am not a. doctor I advise thet you go to the Rural. Health Unt for the medicine. They have a doctor there.” . "Please wait, mother. There might bea problem that can be solved by INCL” ¢. "Okay, mother. There is medicine here that, you need” 4. "Mother, Inced to check him first. There might be 9 more appropriate treatment for baby.” 2. AMler assessing the child, as per the Integrated Management for Childhood Ilinesses (IMCI) in. 2014, the child only has coughs and colds The murse determines that the child should be given a safe remedy. With the nurse's knowledge on herbal medicine, which panitdecoction should he give to the child? ‘a. Oregano leaves b. Five-leaved Chaste tree leaves © Ginger «Young leaves of the Mango tee 3. After two days, the mother retums with the child experiencing asthma. Upon assessment per IMCL, the nurse) needs to nebulize the chilé with inhaled albuterol. The BHS does not have any stock right now but there is a Botika ng, barangay a few meters away that is selling albuterol nebules. What isan appropriate responce of the nurse? ‘a. “Mother, here is a prescription for medicine. Please! 90 to the botika ng barangay right now. They are seling albuterol there. Afterwards, please go back here so that I could administer the drug to, the baby. You can leave the baby here” . "Mother, this isthe prescription for the medicine and the nebulzer. Please go to the pharmacy to buy the nebule. Atterwards, please nebulze the baby.” c. "Mother, here sa prescription for medicine. Please go with the baby to the pharmacy right now. They are selling albuterol there. Afterwards, please 90 back here so that [could administer the drug to the baby.” 4. “Mother let's just cy because your beby might die” 4. Ice wants to know the predominating health problems in the community. AS part of data colection, te performs interviews with random members of the community. During one of his intervews, a man named Argie said that "Come ‘and eat wit us first in our Babang loksa’ before we answer Your question.” What is an appropriate response of the nurse? a. “Igo and eat with you fora bit, but well have to tak about it over the food” b.“L have to refuse. Ym not allowed.” "Tl just say with you." 4."T have to refuse. If you force me, I wil tll on the barangay captain.” 5, Wednesdays, as declared by the Philippine Department of Healthyis the vaccination: dey for children. Ice encounters baby GB, a 9+ month old female. The anti-measies vaccine is prepared, with you knowing that it should be administered through ‘2. Intramuscular route; lower inner quadrant of the luteal area b. Intramuscular route; middle third of the vastus laterals . Subaataneous route; 90° angle 4d, Subcutaneous route: 45° angle ‘Situation: Ice decides to go back to the hospital setting. You, @ new registered nurse and a top notche: in last board exams, gets accepted as the community health nurse with the Position of a Public Heath Nurse IT (PHIV 11). You will provide rursing care to all the members of the communty, regardless of the age and the place of conduct! 6. You mate. ito" point that the BHS is cleaned every day yyou Know that this assists clients to a better state of This notion is in accordance with the theory of nursing 28 Leininger . Oren Mightingale Roy PREVIOUS nurse wanted to) Kfiow the predominating roblems in. thes” community. However, this was not inished. during his Years of service. You, as the new nurse, is for the continuation of the procass. Upon checking ‘you noticed that the persons infected with the 3n_immuncdeficency vieus (HIV) have — exponertialy ed during theyprevious months. AS 2 health care professionalyyou need to protect yourself trom being infected vitus. To avoid being Infected, you know that the that ouneed to do when you hande a dient with 92 a b. om %. Universal Precautions Blood Precautions © Airbome Precautions 6. Contact Precautions 8. For you to conclude that there really is an increase in the cases of people living with HIV (PLHIV), you must know the of PLHIIV in Bray. Cogdara-0. ‘Incidence rete 8. Prevalence rate C. Morbidity Rate . Gender 1 | Poge9. You finished your community diagnosis and planing of programs targeted at reducing the rate of increase in HIV cases. During the implementation, you admitted to yourself that, while you are well-versed with the artificial methods in rami planning, you are not ertirely familiar with the natural methods. You wanted to cooperate with an organization that 's well known for promoting natural family planning and has collaborated with the Department of Health (DOH) for the advocacy. You would calla representative from: ‘. Victory Church ». Catholic Bishops Conference of the Philippines Couples tor Christ 4. Urited Methodist Church 410, During your screening, a mother with a 4- month old fila admits that she is postive for HIV. The records she showed you confirms. that she indeed has contracted the disease. The Mother asks, “Nusse, I read that HIV can be transmitted through breastfeeding. However, my mother said that’s just okay to continue it, despite my status. Which one is really the truth?” What is the appropriate response of the nurse? a. “Ma'am, that is correct. You can pass HIV through breast mik because it was proven to contain HIV. In this case, you can use bottle feeding for your child as, stated by your doctor.” b. °Ma‘am, you should go with breast mik. The chances are low for breast milk to transmit HIV. The benefits of breast feeding outweigh the risks.” c.Ma’am, just give him rice water. I became smart because of thet. Just ball it enough to be steriized” 4. °Ma‘am, you should ask your doctor about that.” Situation: A woman goes into the BHS to ask for a check-up. She complains cccasonal syncope, pallor, and vaginal bleeding, with blood seturating a napkin pad every hour. The lient has just undergone hysterectomy. You, a topnotch nurse, is considering heavy bleeding secondary to surgical complications. You filled up a referral form and calmed the client until the rural health unit's ambulance came to take her into the hospital. The day has passed, and the dient’s husband retumed the referral form, blaming the nurse for the loss of his wife. He sued you for negigence. 11, The court issues an order to summon the MHO and bring all relevant and tangible documents for use in the hearing. What order is this? a. Subpoena ad testificandum b. Subpoena duces tecum Subpoena opera omnia 4, Subpoena bravus exvius 12, Upon investigation, the court found no charting of the incident. Because there was no proof of ‘your interventions, you were found quiy of the charges. In addition, the court charged the MHO because he was the one supervising you, This labilty imposed upon to the MHO Is termed as: a. Assumption of risk b. Res ipsa loquitur Mea maxima culpa d. Respondeat superior 13, Accurate documentation isthe hallmark of nursing accountability, as cictated by the PRC BON Resolution. No. 220, . 2004. This fs also. known as: a. Affirmation of the Board of Nursing as the Regulatory Arm of the Professional Reguletions Commission fer the Profession of Nursing ®. Code of Ethics for Nurses Implementing Rules and Regulations of the Philippine Nursing Act of 2002. 4. Implermenting Rules and Reguiations of the: Comprehensive Nursing Law 114, The nurse, while claiming to have done everything in his scope to help the dient, admitted that he indeed was not able to chart the incident because he forgot about it. This ethical prindple exerted by the nurse is called: a. Veracty . Non-maleficence c. Beneficence . Respect for Autonomy 15, The law governing your practice of the profession as nurse 's called: a. RAQ73L b. RAQ7I c RAQI73 é. RASR7L Sitiiation: Four months after the incident, the family forgives Yyou and the'courtlits your suspension. You deade to apply in ‘@ non governmentalyorganivation (NGO) as a community health nurse, 16. The Projects Director for Public)Heslth of that NGO betBites your intervewex. She asks you about the concept of primary healthcare. You, the most stellar nurse in your batch ‘during your board exams, answers this question with: ‘2.--“To strengthen the health care system by increasing ‘opportunities and supporting conditions wherein people will manege thelr own health care” “Health for all Flipincs, and health in the hands of the people by'the year 2020” ‘co partner with and empower the people towards sefrellance in health care” {ip’Guarantee equitable, sustainable, quality health for all Filipinos” 47. You have been assigned as a clinic manager to the “Post Halyan Community-Based Communicable Disease Prevention Program" of the sald NGO. Upon. your arrival in Guiuan, Eastern Samar, a child vias immediately ‘brought to ‘your post. He was bitten by a dog. Using your knowledge on rabies, you treat the child based on this sequence for the prevention of rabies: 1. Wash with soap and water for 15 minutes TH. Vaccinate with ERIg or HRIg IL. Apply ether 70% ethanol, tincture, or aqueous solution of iodine IV, Observe the dogifor10= 14 days V. Le down, VI Try not to ery. VIL Cry a lt. a. 1, VIL, b.N,V, V1, I ¢ Ul, 1, V1,1 1, 1,1, 18. The next morning, a three-month pregnant mother comes into the clinic. She verbalized, "My boyitiend said that you have a vaccine here for pregnant mothers. What is that vaccine?" This vaccine is: 2. Measles, Mumps, Rubella (MMR) vaccine bi. Tetanus Toxoid (TT) «. Anti-Measles Vaczine (AMV). <4. Pentavalent Vaccine (PentaHib) 419, The mother shows fl vactination record. It was indicated she was first vaécinated for TT on June 12, 2018. If today’s dateisJuly 16, 2018, the next dose should have been given on: a. July 2, 2018 b. December 12, 2018 June 12, 2019 Today 20. If the pregnant mother’s vaccination record shows that ‘she was given 3 DPT doses during childhood, when will be the next dose? 2. July2,2018 b. December 12, 2018 © June 12, 2018 4. Today Situation: After spending 5 years in the program. you decided that'you want to be a maternal and child nurse (MCN) inyEuracia Vienna Regional Medical Center (EVRMC). As an MN, you are tasked to take care of pregnant mothers and their newborns. 21. During your break on your first day, you decided to go to the staff room. You found out that your head nurse vas injecting an unknown liquid in his arm. Your priority nursing action is: 2. Stop the head nurse from injecting that liquid. b. Report the incident to your charge nurse Report the incident to the nurse supervisor 4. Ask the police to kill the head nurse because he is an “adik” and deserves to die, as dictated by a certain high-ranking poiticion 2 | Pose22. After responding to that event, you admitted a laboring 37-meek pregnant mother who was pregnant 4 times prior, with 3 babies reaching childhood. All prior pregnancies reached term, but 1 child died 30 minutes after birth. There were no preterm deliveries. What is the mother's obstetric score? aG4T4P0A0L4M0 b.GSTSPOAOLSMO ©.G4T3POA0L3M0 d.G5T4PO0AOL4MD 23. You now have a total of 8 single-gestation spréghant mothers under your care. How rrany are your lierts? a8 b.16 or ais 24. Your current hospital is a facility that provides all basic emergency maternal ard neonatal care, with the addition of blood transfusons and caesarian deliveries to mothers. With your experience in the community, you know that. this the highest level in the four-tier service delivery madel, Recalling, what is the frst level in this delivery model used in the Philippines? a. Comprehensive Emergency Obstetric and Newborn Care (CEMONC) b. Basic Emergency Obstetric and Newborn Care (BEmONC) €. Baie Essential Obstetric and Newborn Care (BEONC) 4. Community-based Teams (CBTS) 25. In a CEMONC facilty, which of the following Is NOT a part of the team? a. Midwife b. Nurse Surgeon 4. None ofthe Above Situation: While you are a stellar MCN and CHN, your friend Dindin is an excellent pediatric nurse, She is assigned in the pediatric surgical ward, 26, Dindin ie caring for 2-year-old child named CP. CP is diagnosed with Pylori Stenosis. The child comes back from the Post-Anesthesie Care Unit (PACU). Knowing the surgical procedure needed to correct the problem, Dindin is expecting that the child i status post- 2 a. Fredet-Ramstedt Procedure 5. Swenson Pulthrough €. Boplortory Laperotomy, Total Abdeminal Hysterectomy and Bilateral Salpirgo copherectomy (EL-TAHESO) 4. Lobotomy 27. The resident physician orders for CP's urine output to be, ‘monitored hourly. If CP weighs 12 kg, her regular hourly output should be approximately: 2.6ce b.Adec c24ce 4. 36.cc 28, During the first hour of thé Glent after the surgery, Dindin netices that the child having slow respiratons of about 18 cycles/minute (CEM). Dindins priority nursing action is to! a. Monitor the dient and document findings. . Provide oxygen of about 2 iters/minute (LPM) via face mask c. Refer to physidan 4. Start Cardio: Pulmonary Resuscitation (CPR) 29, CP hes an abdominal wound that has never been Cleared after the surgery. The surgical consultant orders that the surgical wound be cleaned every 8 hours by the nurse on duty. Dindin’s first nursing action is 2. Use povidone-iodine to lean the wound ®. Wash hands with soap and water Ask the resident physician to Gean the wound 4. Clarity the order with the consultart 30, CP’ father asks if the baby's thumb-sucking Is. normal. She explains tothe father that the child is inthe “oral phase", according to a psychoanalyst named Freud. Dindin dleplaye. her knowiedge on the poychosexsal stages if she states that: (SELECT ALL THAT APPLY by encircing all possible letters of the correct answers) a. An infant sucks for nourishment & pleasure b. An infant does not find pleasure in sucking but does find terjyment ‘rom the percepticn of nourishment from the thumb ‘An infant may haVémore pleasure in breastfeeding than in battle feeding because. it expends more energy Aun infant does not find pleasure on a pacifier €,Anlinfant explores the world through her mouth F. An infant begins to explore the genital area_to learn sexual identity a AGE b. BCE ABE 4. DED ‘Situation: The nursing staff of the pediatric neurology ward is having @ mid-year staff outing. Dindin was asked to relieve inthe area. 31. Dindin is preparing a 4 year-old intersex dient for ‘raniotomy. Which nursing action is appropriate for preoperative teaching based on Erksor’s developmental stages? ‘a. Allowing the child to make a project related to the surgery b. Having the child put a surgical mask ona_doll Asking the child how he feels about surgery 4. Allowing the child to listen to music without further instructions 32. Dindin preperes the child's medications. The mother says, “My baby is afraid of strangers and afraid of separating from me. My mother in-law is upset and thinks 1 am causing it.” Which response'by the nurse is most appropriate? “Give your baby to strangers while you are present, sohe gets used to stangers.” b. “Your mother-indaw is correct; youneed to include her more in your baby’s needs” € “Separation anxiety is an important component of a parent-child attachment.” 4. “Just let your baby ery for a while; your baby will get Used to being separated from you.” 33. A 15 year-old transweman client previously diagnosed with a pituitary adenoma is about to be discharged. The parents were taking care of the child's hosptal clearence When Dindin approached the adolescent. She told the nurse that, “Lhave something to say to you, but I beg: you, do not tell anyone about this” Dindins- most appropriate action would beto: ‘2. Promise the efi that the infermation will not be told to anyone. ‘bof Tell the client thet the information will be confidential Unless Is fe threatening or harmful. Tel the client thet only the physician willbe told; ‘otherwise the information will remain confidential .__Asicthe client to tell a social worker who. then can Tolow through with the information it itis concerning. 34, Dindin is assessing an infant for attachment behavior. Which obse-vations ere important in assessing this relationship (SELECT ALL THAT APPLY by encircling all possible letters ofthe comect answers) '2. The kind of body contact between the parent and infant b. Ifthe parent is hoding and cuddling the infant 16: The kind of comfort techniques being used by the parent d. The comfort level ofthe parent while interacting with the baby ‘€. Whether the infant is crying 2. ABDC b. BAD.C © ABCD 4. DBA 35, A rursing care plan is being made by Dindin for e child who iss/p removal of brain tumor. The child is confused, disoriented, and restiess. Which nursing diagnosis should receive the highest priory? 2. Allred Sensory Perception rt neurological surgery b. Sef. Care Deficit r/t confusion and disorientation Impaired Verbal Communication r/t confusion 3 | Poge4. Risk for injury s/t disorientation and restlessness Situation: A strong earthquake has recently hit the Province of Morgana. EVRMC was asked by the Local Government Unit of Morgana and the DOH to send health care providers. You, Dindin, nd two other colleagues named Vina, and Jousch were deployed. You were to provide primery health care as supervised by the Municipal Heakh Officer 36. Dindin was assigned to provide reproductive health (RH), services to the Manunubang. She helped a mother to deliver the newbom. She was about to pul the placenta, The cord was lengthening and there was a sudden gush of ‘blood. She is now only waiting for the uterus to. become firm and lobular. This sign that Dindin is wating fori calle ‘a. Cullen's Sign b. Gulkn’s Sign . Chadwick's Sion 4. Candor’s Sign 37. A nursing supervisor from a known O8-Gyre hospital in Mania told Dindin that what she did is termed as the expectant management of the third stage of labor. However, as per new eviderce, the Phlippinesis moving towards the active menagement ofthe third stage of labor (AMTSL). The components of AMTSL. includes the following EXCEPT: ’. Giving a uterotonic drug to contract the uterus (oxytocin) », Controlled Cord Traction €. Delayed Cord Clamping 4. None of the Above 38, Vina and Jousch were assigned to provide primary health care to adult dents. Jousch claimed that she was told by the MHO that she is given permission to diagnose and prescribe medicines to adult clients by virtue ofan interim primary health care guideline for first level health workers. Jousch wes referring to: a. International Guidelines on Medical Diagnoses for Nurses . Nurse's Primer for Advanced Primary Heath Care €. Integrated Management of Adult and Adolescent Illnesses (IMAL) Emergency Medical Training Guidelines for Aled Health Professions 39, After the incident, Vina decided to go out with the ‘emergency response team and looked for people needing help. She saw a man standing near a house. Because Vine is knowledgeable about Psychological First Ald (PFA), she approached him and introduced herself. The man told her “fm Tarib Yorimit. I'm scared! I was about to come home from the farm when it started sheking! T dontounderstend what is happening!” Vina's best response for Tarib is: a. “You should have run away from your house, Iécould be dangerous.” b. "Yes, a 4.5 magnitude earthquake with the epicenter at Feta, Morgana and @ hypocenter at about 79 miles deep into the earths crust happened” c. “Everything wil be okay. You willhave anew house. The government will surely ive you a job with a salary of 10,000 pesos per month for a decent living. You just have to work hard and not be lazy.” "Yes, it was an earthqueke and Iican imagine t was terrible for you. Its not safe in this area for now, and you might get hurt” 40, Francois, an emergency roof nurse, is assigned asa triage nurse in the emergency center ofthe hospital. She receives four admissions. Prioritize the order in which, Francois will assess the clients. 1. A40 year-old client who is diaphoretic end is feeling chest pressure I, An 18 year-old client who thirks he might have a broken ankle I, £35 year-old dient who cut her hand with a krife preparing for food 1V.A60 year-old clent who is dyspneic ard has swolen lips after being stung by a bee a. 1,1, b.MLUL OT Nt, 1 4,10, 1,11 Situation: As a care specialist, a nurse should be knowledgeable on socio-political aspects of health care. 41. The Philispine Health Agenda, 2 national health development plan ceated during the period of the DOH ‘Secretary Pauly. Ubial, aims to attain the nealth-reated ‘Sustainable DeVelopment Goal (SDG) Tarcets. With its development, goals were defined. by formulating its so-called "Guarantees" Which of the following statements are NOT includedin the Guarantees? @. Servicessfor Both Well and Sick bb. Functional Network of Health Facilities ‘c. Firancial Freedom Whien Accessing Heath Services d. Advance Quality, Health Prometion, and Primary Care 442)\The'SDG in which the PHA is patterned from is the: a. SG 1 b. S062 ©5063 d. SOG 4 43)PHAS Guarantee 1 ensures that all fe stagésiand the triple burden of disease is addressed. This includes attention to ‘Non-Communicable Disease (NCD) and Malnutrition. In the Philippines, what is the protocol used to screen, diagnose and manage NCDs in the primary health care level? a. PFA b. PhilPEN. . OSHS . uhGAP 44, Communicable diseases are a problem that continues to tveaten child health. To combat. the rise in morbidity, the Philippines s implementing what is known as the National Immurization Program. This program is mandated by: a. RA 10152 . PD 995 RA 7305 d. PD 855 45, The current administration has appointed a new DOH secretary. He wants to use a strategic approach that will “enable the heath department and the public to monitor how the health sector is working to achieve better timeliness, better responsiveness, better quality, and better outcomes for patients” This strategic approach 's thereby dubbed as: 2. Duterte Health Agenda (DHA) ‘i. Fourmuia One for Health (F1) . FI Plus ¢. DHA Plus Situation: As a nurse well-versed in the’ holism of care, you provide care to people in various places and situations. 46. You are welling to the Rural Health Unit when a jeepney hit two persons walking on the pedestran lane. Client A, an ‘adult, was bleeding from the abdomen, and is vibly having a difcity in breathing. As the first. responder, you identified yyoursef as a halth care professional and proceeded to the scene._Whatts the frst nursing action that you should do as ‘you approach the client? 2, Assess the client for cervical njutiés b; Stop the client's bleeding . Check if the seat is safe 4. Inset’@123G IV cannula for PNSS to replace blood last -479AS|you assess lent A, you noticed that the lent is Unable to move his uaper and lower limbs end the airway is ct open. You are suspecting’a cervical spine injury. Which of the folowing metho should you use to open the arway? 2. Head-tit/chivit technique , Medified jaw-thrust maneuver Ritgen’s Maneuver . Crede's Manewver 48. You noticed that there is a glass shard stuck in the client's abdomen. Whatis the nurse's priority action with regard to the glass shard? a, Remove the glass shard b: Stabiize and secure the impaling object in place €: Pushit deeper to prevent bleeding 4 Let the surgeon handle it 49. After 15 minutes, the lint is sil bleeding out, despite nursing interventions. The EMT has stil not arrived in the cane. You noticed that the client & having respirations of 30 4 | PoseCCPM, PR of 120 BPM, and BP of 70/50. You are now suspecting that the client isin: ‘a, Cardiogenic Shock b. Anaphylactic Shock c. Hypovolemic shock 4G. Electric shock 50. Ifa person is already in shock and has no head and/or abdominal injuries, what is the most appropriate position for the dient? 2 Supne with legs elevated b. Trendelenberg . Dorsal Recumbent d. Lithotomy Situation: Research is essential to the nursing practice. It enables a nurse to have continuing. professional development and to provide quality, safe, and up-to-date care fer clients. 51, You, a very successtul and ineligent nurse, decides to research on the effects of music therapy in pain relief on children during phlebotomy. Which ofthe following is the! dependent variable? ‘a. Amount of music therapy Pain relief during phlebotomy . Children, Indiscernible from the given data 52. Which ofthe following isthe independent. variable? ‘a. Amount of music therapy Pain relief during phlebotomy . Children dd. Indiscernible from the given data 53. I the study is quantitative and the standard deviation is, known, which of the folowing statistical tests should the nurse use in the research? ‘a. One-Sample Z-Test b. One-Sample T-Test ‘c. Chi-Square Test of Association . ANOVA 54. The responses that the nurse will analyze comes directly from the perceptions of the children in the study. These responce: are research data that are taken from a: 2. Primary Data Source b. Secondary Data Source Tertiary Data Source d. Quaternary Data Source 55. You wanted to use a measure of central tendency to ‘summarize information about the distribution of data. Which Of the following measures of central tendency has a tendency to be affected by data outliers? a. Median . Mode c Mean d. Standard deviation, Situation: As a health care professional, whether you are ‘working in the commurity or in the hospital, you are tasked to, provide nursing care when unforeseeable crises Occur, 56, A few minutes after you made a reservation for massage, YoU heard something hard hit the pavement. Immediately fer he led down, you sav him with what appears as jerking ‘movements from all over his body. As per assessment, he has lost his consciousness. You know that the client Is experiencing! a. Simple partial seizures b. Complex patil seieures Generalized seizures 4. All ofthe above 57. Which ofthe flowing nursing interventions are inappropriate tor the clent curing the attack? 2. Do net restrain the client B: Loosen his dothing €. Place a small, folded blanket under the head 4. Place a tongue guard in his mouth 58, Whats the position of choice forthe dient during the seizure attack? a. Dorsal recumbent b: Side-¥ing Supine 4. Tendelenburg 59, The Emergency Medical Team has arrived at the scene, ‘You identified yourself as a registered nurse explained the situation and gave a brief background on the EMT. ‘Assessment parameters were given and recommendations to takeithe client to EVRMC were reiterated. This type of referral 660. One of the EMT rescuers took the dlent’s blood pressure. He records it at 200/120 mmlig. As per the 8* Joint National Commission Guidelines, this is dassfied as: a. Hypotension bbaNormotension €. Stage | Hypertension d. Stage II Hypertension situation: You are @ dlnic nurse providing care to cients with jehconic and terminal ilnesses. 661. You are teaching an 18-year-old diabetic client to perform ‘selfadminisration of insulin. The nurse notes that each time the cient makes even a small mistake, the client constantly apologizes for getting it wrong. The nurse” cbserves that the Glient also profusely apologizes when making a minimal mistake in other activities. The nurse concludes that, according to Erikson’s development stages, the. aduit may have an unresolved development task of: a. Infancy. D. Early childhood, . School-age childhood. d. Adolescence. 62: cient states; "IF T/C0UId lve until my_orandson’s wedding in2 months, then I would be ready to die” Based on this statement, you should interpret that the client is in which stage of grief? a, Denial b. Depression € Bargaining d. Accepeance 63 You ate caring for a middle-aged client who is disabled due toa recent motor vehicle accident. The client has few interests, spends most days watching TV, and has become estranged from the family, Which of Erikson’ developmental stages should the nurse conclude that the clent is NOT meeting? 2 Industry versus inferiority b. Initiative versus guilt . Generatvity versis stagnation 6. Intimacy versus solation 64,25-jear-old client, who had a tysterectomy due to uterine ‘cancer tells you, "My hushand will probably leave me now because Iwon't be able to have any more children. Iam so ‘9lad Thave one child already’ Which response by you is most 2eoropiate “That probably vion't happen. He'l ikely be thankrul that you already have one. chid.” 'b, "Are You afraid your husband will leave you because he wants more children?” ¢_"Tnefé are support groups you and your husband {could aitend to help cope with your loss.” d. "Your husband sould be thankful that you are alive and didn’t bieed to death!” 165. A €0-year-old client, admitted to a hospital with chest pain, has besh functioning independently at home. During the night, the dlientis feund wandering in the hallway and states, Icanttfind my kitchen. Ineed a gass of milk” Your best interpretation of the clients behavior is: ‘2. The client likely had a stroke. b. The stress of being in unfamiliar surroundings has caused the client's. confusion. The dedine in mental status, especially at night, is a normal part of aging, 4d. This isan insidious change and it likely means the client has early dementia. Situation: In the Philippines, there has been a se in mental health illnesses. About 1 in 3’ Filipinos die every year from suide 5 | Poge66, Which nursing diagnosis should a nurse give highest priority when caring for a client with major depressive disorder? 2. Powelessness . Compromsed Human Dignity . Risk for Self and Otner- Directed Violence 4. Disturbed Sleeoing Patterns, 67. A nurse is meeting with a client who is being discharged after hospitalization for suicidal ideation. Based on knowledge. of expert consensus of warning signs for suicide, the snurse should plan to advise the client to seek help by Contacting ‘mental health professional or caling the national suicide Prevention hetline if experiencing: (SELECT ALL THAT APPLY by encircing all possible letters of the correct answers), a. Sadness, ». Hopelessness. c. Severe Anxiety and Agitation. 4, Feeling of Being Trapped. . Increasing Alcohol or Drug Use. a CDE b ABCD & BCE 4. AGO 68. You are reviewing Get restrictions with 2. suicidal cient taking a monoamine oxidase inhibitor (MAOI). Which symptom could occur with non-adherence to et restrictions while taking @ MAOI? ‘2. Agranulocytosis b, Exphsive Ocdpital Headache Severe Hypotension 4d. Akathisia 69, An experienced nurse is teaching a new nurse about establishing therapeutic relationships with clients on a mental health unt. Which inte-vention should the nurse suggest ‘when attempting to establish a therapeute relationship with a dlient diagnosed with major depressive disorder? 2. Sit withthe cient in silence b. Ask the dlientto join others to watch a 2- hour movie. Invite the client to attend an exercise class. d. Ask the dlient how his or her day should be scheduled. 70. A depressed client tells a nurse, “Nothing dives_ me joy. Things seem hopeless." Which actions should be you take nn caring fr ths cent? Prontize the nurse's actions ore Demonstrate genuine empathy and caring in discussing clients feelings about suicde. IL. Evaluate the cient’ risk for suicide by direct questioning (asking about suicide intent and plan). IIL. Initiate suicide precautions as needed, according to policy and standards of care. |V. Continue to support and monitor prescribed medical end psychesocal treatment plans. \V. Assist client in maintaining nutritonal needs, hygiene, and erooming, VI. Contact the client's support system in collaboraton with case manager and/or social services. 2.11, WL, V1 1, V1 bM, 0, LV, I 1, 1 1Y,1y VE 1H 11,1. V.VE Situation: You are a newly hired registered nlFS@taking care Of clients with mental illnesses. 71. You are assessing a recently admitted client. who 1s exhibiting agitation that appears to be related to acute mania. Which action should a. nurse plan to utilize when caring for 2 dient experiencing agitation related to acute mania? ‘2. Apply restraints to prevent the client from harming self or others ® Involve the dlient in group activities to provide structure Leave the client alone 4. Maintain a low level of stimull in the client's environment 72. You are assessing a cient recently admitted to a psychiatric unit who experiencing acute mania. Which rhussing action should the nurse plan when caring for a client with acute mani a, Sustain conversations to improve the client's ‘edlicentration. B. Provide finger foods that the client can carry while ‘moving around the unit. c. Teach the client and family about avaliable ‘community resources 4d. Help the ‘amily understand that anger directed at them is likely tojescaate unless they confront the clients behavior. 73, You are caring for a clent diagnosed with, acute mania, Yoll observe coarse hand tremors. and learns thet the client's ‘serum lthiumn|level. is 1.8 mEq/L. Which action should be you take? 2. Continue to adminigier tum as ordered. ». Advise the client to imi fluids. {caMithhold the medication and notify the! physician. 4. Acknowledge thatthe cide effects are unpleasant 74, Which goals should be included inthe plan of care fora dlient with dementia? (SELECT ALL THAT APPLY by encircing all possible letters ofthe correct answers). a. The client will remain physially safe, b. The dient will receive emotional support. The dient will receive physical health care. 4. The dient will show cognitive improvement. e. The client will function at highest level of independence £. The dient will perform actives of daly. ving independently. A. BCDE B ABGE C CDEF D. BCE 75, A dient diagnosed with delirium is restrained in order to prevent the removal of a Foley catneter and an intravenous fluid line. Which response should you expect after the client is restrained? ‘2. The client rests better at night B. The dient becomes visibly aitated. ‘Te cushions and protects the baby. ‘Te maintains the temperature of the baby. = Tt s the way the baby gets food and oxygen It. prevents all antibodies and viruses from passing to the baby. Te provides an exchange of nutrients and ‘waste products between the mother and ~~ developing fetus. 9. The nurse is providing instructions to 2 ‘clent who is scheduled for an ‘What instruction should the nurse (Strict bed restil required after the procedure. i. ._ Hospitalization is necessary for 24 hours after the procedure. An informed consent needs to be signed before the i procedure, | ‘A fever is expected after the procedure because of the trauma to the abdomen. 10. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, Calorle:s vaginal drainage. The nurse should make which statement to the client? ‘A. "Come to the dlinc Immediately.” B. "The vaginal discharge may be bothersome, but is a normal occurrence.” C._ "Report to the emergency department at the ‘maternity center immediately.” 1 | PogeD. “Use tampons ifthe discharge is bothersome, but be sure to change the tampons every 2. hours.’ LL. A nonstress test is performed on a client who is pregnant, ‘and the results of the test indicate nonreactive findings The primary health care provider prescribes a contraction .streSs test, and the results are documented as negative: HOW shoud the nurse document this finding? |. Anormal test result 3B. An abnormal test result . A high risk for fetal demise . The need for a cesarean section 12. The nurseiin a health cere cinicis instfucting a pregnant client how to perform "kick counts.” Which statement by the dient indicates a need for further instruction? |A."Lwil record the number of movements or kicks.” B. “Ineed to lie flat on my backito perform the procedure.’ C. “IFT count fewer than 10 kicks in a 2-hour period, L should count the kicks again over the next 2:hours” DL “T-should place my hanés on the largest part of my abdomen and concentrate on the fetal movements to count the Kicks, 13. The nurse's performing an assessment of 2 pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height s 30 cm. How should the nurse interpret this finding? [A The client is measuring large for gestational age. 8. The client is measuring small for gestational age. C. The client is measuring normal for gestational age. D. More evidence is needed to determine size for gestational aoe. 14, The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the dlent for probable signs of pregnancy, The nurse should assess for Which probatie signs of pregnancy? Select all that apply. ‘A. Bellottement B. Chadwick's sign C. Uterine enlargement D. Positive pregnancy test E, Fetal heart rate detected by a nonelectronic device F. Outline of fetus via radiography or ultrasonography 15. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions, The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of ths finding, which nursing acto is appropri? Contact the primary health care provider. Bip Insrct the Cent to malta bed ra forthe remainder of the pregnancy. Inform the client that these contractions are ‘common and may occur throughout the pregnancy. D. Cll the maternity unit and inform them that. the dlent will be acmitted ina preterm labor condition, 16. A client arives at the clinic for the firs prenatal faccesement, She tells the nurse that the first day of her last ‘normal menstrual period was October 19, 2020. Using Naegele's rule, which expected date of delivery should tie: nurse document in the client's chart? ‘A. July 12, 2021 8. July 26, 2021 C. August 12, 2021 D. August 26, 2021 17, The nurse is collecting éata during an admission assessment of a clent who is pregnant with twins. The client has a healthy 5-year-old chiid who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what chould the nurse document in the client's chart? 18. The homecare nurse iss a pregnant cen who has a diagnosis of preechmpsia. Which astessment finding indicates a worsening ofthe preeclampsia and the need to ratify the primary health care provider (PHCP)? ‘A. Urinary output has increased. B. Dependent edema has resolved. . Blood pressure reading is at the prenatal baseline. Dips The client complains of a headache and blurred vision, 19, The nurse impiéinents a teaching plan for a pregnant client who is newly dagnosed with gestational dabetes imalitus. Which statement made by the cert indicates a need for futher teaching? "I Shouid:stay on the diabetic diet." "I should perform glucose moritoring at hore." "I should avoid exercise because of the negative effects on insulin production." Dijp'l shouid be aware of any infections afi report signs of infection immediately to my obstetrician.” 20. The nus is performing assessment on a pregnant soient in the ast trimester with a dagnosis of preeclampsia. ‘The mirse reviews the assessment findings and determines that which finding is most closely associated with a complication ofthis diagnos? Enlargement of the breasts 3 Complts af feng hot when the room i col C._ Periods of fetal movement followed by quiet periods D. Evidence of bleeding, such as in the gums, petechiae, and purpura 21. The home care nurse is monitering @ pregnant client who is at risk for preeciampsia. At each home care visit, the nurse ‘essesses the client for which sign of preeclampsia? ‘A. Hypertension B. Low-grade fever C. Generalized edema D. Increased pulse rete 22. The nurse is assessing a pregnant dient with type 1 diabetes melitus about her understanding regarding ‘ranging insulin needs during pregnancy. The nurse determines that further teaching is needed ifthe dient makes which statement? ‘A. "Twill need to increase my insulin dosage during the first 3 months of pregnancy.” B. "My insulin dose will kely need to be increased during the second and third trimesters.” (C._ "Episodes of hypoglycemia are more likely to occur during the frst 3 months of pregnancy.” D._ "My insulin needs should return to pre-pregnant levels within 7 to 10 days afterbirth if am. bottle-eeding. 23. A pregnant dient rep6mts to @ health care dinic, complaining of loss of appetite, weight loss, and fatique ‘Afterassessment of the dient, tuberculosis s suspected. A ‘sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teachingiplan? ‘A. Therapeutic abortion is required. £8 Isoniazd pilus rifampin wil be required for 9 months, C. She will have to stay at home until treatment is completed. 'D. Medication will ot be started until after delivery of the fetus. 24eqTH8 nurse is providing instructions to a pregnant client ‘with ahistory of cardiac cisease regarding appropriate dietary measures. Which statement, if made by the clent, indicates_an understanding of the information provided by the nurse? ‘A. "I should increase my sodium intake during pregnancy.” B, "should lover my blood volume by limting my fluids." CC. "T-should maintain a iow-calorie diet to prevent any weight gain.” D. "Ishouid drink adequate fluids and increase iy intake of high-fiber foods.” 25. The clinic nurse is performing a psychosocial assessment ‘of a client who has been told that she s pregnant. Which assessment findnas indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. ‘A. The client has a history of intravenous crug use. Qe> 2 | PoseB. The dient has a significant ether who is heterosexual. C. The dient has a history of sexually transmitted infections, D._ The dient has had one sexual partner for the past 10, years. ‘The dient has @ previous history of gestatinial diabetes melitus. 26. A lent in the first trimester Of pregnancy arrives ata health care nic and reports that. she has been experiencing vaginal bleeding, A threatened abortion is suspected, and the nurse instructs the client regarding ranagement of re. Which statement made by the dientindicates a need for further instruction? A "Iwill watch to see if T pass any tissue.” 8. “Iwill maintain strict bed rest throughout the remainder ofthe pregnancy. "Twill count the number of perinal pads used on a daily basis and note the amount and. color of blood on the pad.” “Lwill avoid sexual intercourse until the bleeding has stopped and for 2 weeks folowing. the last episode of bleeding.” 22. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potertial dient needs should the nurse anticipate? Select all that apply. |A. Bed rest s a necessary preventive measure may be prescribed B. Administration of subcutaneous heparin post delivery a5 prescribed ‘an overbed lit may be necessary ifthe dient requires @ cesarean section. D. Less frequent cleansing of a cesarean incision, f present, may be prescribed. Thromboembdlism stockings or sequential compresson devices may be prescribed. 28. The murse is performing an assessment on a client who has just been told that a pregnancy testis positive Which assessment finding indicates that the client is at risk for, preter abo? The dient is a 35-year-old primigravida. The dent has a helo of croc does. C. The dient’s hemoglobin level is 13.5 g/dL (135 mmdi/.), D. The dient is a 20-year-old orimigravida of average weight and height 29, The nurse provides instructions to a malnourished regrant.lient regarding iron. supplementation. Which dliert statement indicates an understanding of the instructions? |A. “Tron supplements wil give me diarrhea.” B. "Meat does not provide iron and should be avoided." C. "Theron is best absorbed if taken on an empty stomach." D. ‘On the days that 1 eat green leafy vegtables oF ca iver I can omit taking the ron. supplement.” 30. During a routine prenatal vist client complains of gums that bleed easly with brushing. The nurse performs an assessment and teaches the client about proper iutrition to minimize this problem. Which client statement indicates an understanding ofthe proper. nutrition to minimize this probem? A "I will drink 8 o2 of water with each meal.” 8. "Iwill eat 3 servings of cracked wheat bread each day." “Lill eat2 saltine crackers before I get up each moming. D. "Iwill eat fresh fruts and vegetables for snacks and for dessert each day." 31. The nurse in a maternity unit is reviewing the ents! records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (OIC)? Select a that apa [A primigravida with abruptio placenta 3A pinigrovida who delered 10h nfant 3 hous ago CA cgravida 2 who has just been diagnesed with dead fetus syrdrome c. D. A gravida 4 who delivered 8 hours ago and tas lost 500 mL of biood E. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Bile nurse is assessing a pregnant client in the second {rimester of pregnancy wno was admitted to the maternity tun with a suspected diagnoss of abruptio placentae. Which assessment finding should. the rurse expect to note if this condition i present? ‘Al'Soft abdomen B, Uterine tenderness Absence of abdominal pain 1. Painless, bright red vagnal bleeding 33, The maternity nurse is preparing for the admission of a Gichitipin..the third trimester of pregnancy. who is ‘experiencing vaginal bleeding and has a suspected diagnesis ‘of placenta previa. The nurse reviens the primary health care. Provider's prescriptions and should question which resction? Prepare the client for an ultrasound, ‘Obtain equipment for a manual pelvic examination, Prepare to draw hemoglobin and hematocrit blood sample. Obtain equipment for external electron fetal heart rate monitoring. 34. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that epply. on> 9 Uterine rigicty Uterine tenderness Severe abdominal pan Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age 35. The nurse is cating for a cient in labor. Which assessment findings indcate to the nurse that the lent ie beginning the second stage of labor? Select all that apply. A. The contractions are regular. B, The membranes have ruptured C.Thecervix is dilated completely. D. Theelient begins to ex0el dear vaginal fuid. E. The Ferguson reflex is initiated from perineal pressure, 236. The nurse in the labor room is caring for a dent in the active stage ofthe first phase of labor. The nurse is assessing the feral pattems and notes @ late deceleration on the monitorestrip. What is the most appropriate nursing action? ‘A. Administer oxygen via face mask B, Place the mother in‘eSupne position. €._ Increase the rate of the oxytocin intravenous infusion, ._Dacufient the findings and continue to montor the fetal patterns, 37, The nurse is performing an assessment of a client who is, ‘Scheduled for a cesarean. delivery at 39 weeks of gestation. ‘Which assessment finding indicates the need to contact. the primary heelth are provider (PHCP)? ‘A, | Hemogiobin of 11 g/at_ (110 mmol/L) B. Fetal heart rate of 180 beats per minute C__ Maternal puise rate of 85 beats per minute 'D. White blood cell count of 12,000/mm3 (12 x 109/L) mmoos> 38. dient arrives at a bithing center in active labor. After ‘examination, itis determined that her membranes are stil Intact and she is at a -2 station. The primary health care [provider prepares to perform an amniotomy. What will the rhurse relay to the client as the most likely cutcomes of the amniotomy? Select all that apply. Less pressure on her cervix Decreased number of contractions Increased efficiency of contractions The need for increased maternal blood pressure ‘monitoring ‘The need for frequent fetal heart rate monitoring to detect the presence of a prelapsad cord pne> 3 | Poge39, The nurse is monitoring a client in labor. The nurse suspects umbilical cord. compression if which is noted on the external monitor tracing during a contaction? |. Variability 8. Accelerations C. Early decelerations D. Variable decelerations 40. 4 dentin labor is transported to the delivery room and prepared for @ cesarean delivery. After the client is transferred to the delivery room table, the nurse Should place the client in which postion? | Supine postion with a wedge under the right hip 8. Trendelenburg's postion with the legs in stirups C. Prone positon with the legs separcted and elevated . Semi-Fowler's position with a pillow under the knees. 41. A rubella titer result of ¢ 1-day postpartum dient is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provices which information to the lent about the vaccine? Seledt all that apply. |A. Breast-feeding needs to be stopped for 3 months. 8B. Pregnancy needs to be avoided for 1 to 3 months. C. The vaccine is administered by the subcutaneous route. D. Exposure to immunosuppressed individuals needs to be avoided. E._Abypersensitvty reaction can occur F the client has an alleray to eggs. F. The area of the injection needs to be covered with e sterile gauze for 1 week. 42. The nurse_is providing instructions to @ pregnant client: with human immunodeficiency virus (HIV) infection regarding care to the newbom after delivery. The client asks the nurse about the feeding options that are availabe. Which response should the nurse make to the clent? ‘A. "You will need to bottlefeed your newborn.” 8. "You will need to feed your newborn by nasogastric tube feeding.” “You willbe able to breast-feed for 6 months and then will need to switch to bottle feeding." D. "You will be able to breast-feed for 9 months and then will need to switch to bottle feeding, 43. Astilborn baby was delvered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the beby. Which statement by the nurse would assist the family in their period of grief? ‘A. “Whet can I do for your" 8. ‘Now you have an angel in heaven.” C. ‘Dont worry, there is nothing you could have done to prevent this from tappening.” D. "We will se to it that you have an early discharge so that you don'thave to be reminded. of this experience." 444, The nurse in a maternity unit is providing emotiotat support to a client and her_ significant other who are preparing to be discharged fromthe hospital after the Birth of 2 dead fetus. Which statement made by the client indicates a component of the normal grieving process? ‘A. "We antto attend a support group.” B. "We never want to try to have a baby agai "Weare going to try to adogt a cid immediatly.” D. "We are okay, and we are going to try to have another baby immediately." 45, The nurse evaluates the abilty of a hepatitis B-postive mother to provide safe bottle feeding to her newborn during postpartum hospitatzation. Which maternal action best exemplifies the mother's knowledge of potential disease trancmission to the newborn? 'A. The mother requests that the window be dosed before feeding. 8. The mother holds the newborn propesty during feeding and burping. The mother tests the temperature of the formula before inating feeding. D. The mother washes and dries her hands before and after self-care ofthe perineum and asks for a pair of gloves before feeding, 46. The nurse in the postpartum unit is caring for a cent who has just delivered a newborn infart folowing a pregnancy wth placerta previo. The nurse reviews the plan of care and DtBpares to moritor the dient for which rsk associated with placenta previaz ‘A. Infection 8 Hemorthage C. Chronic hypertension DDippDisseminated intravascular coagulation 42, The postpartum nurse s taking the vital signs of e client ‘who delivered ahesthy newborn 4 hours ago. The rurse notes that the clents temperature is 100.2° F. What isthe piorty nursing action? ReDocumert the findings. B. Notiy the obstetrician. (C Retake the temperature in 15 minutes. D. nerease hydration by encouraging oral fids. *48,.The nurse Ts assessing a dient who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nixse of feelings of faintness and dizziness. Which nursing action is most appropriate? ‘A. Raise the head ofthe client's bed. 8. Obtain hemoglobin and hematocritlevels. CC. Instruct the dent to request help when getting out of bed. D._Inform the nursery room nurse to avoid bringing the newborn to the chant until the client's symptoms have subsided. 48. The postpartum nurse is proving instructions to a dent ater birth of a heathy newborn. Which time frame shouid the nurse relay to the client regarding the return of bowel function? ‘A. 3 days postpartum 8.7 doys postpartum On the day of birth D, Within 2 weeks postpartum 50. The nurse is planning care for a postpartum client who had a vagiral delivery 2 hours ago. The client required an ‘episiotomy and has several hemorrhoids. What is the Pforty nursing consideration fr tis client? ‘A. Gent pain level B Inadequete urinary output C.Glent perception of body changes D. Potential for imbalanced body fuid volume 51. An infant receives a dphtheria, tetznus, and acellular pertussis (DTaP) immunization at 2 welk-baby dln. The parent returns home and calls thé lini to report that the invant nas developed swelling and redness et the site of injection, Whichlintervention should the nurse suggest tothe parent? ‘A. Monitor theinfat fora fever B, Bring the infant backto the clinic. ©. Apply « hot pack to the injection site, . Appia cold pack to the infection ste. aed receiving a series of tne nepattis BVacane and ‘rives atthe clinic with his parent forthe second dose. Before administering the vaccine, the nurse shoud ask the child and parere about a history ofa severe allergy to whch substancea A Eggs B.Peniilin Sulfonamides 'D. A previous do8® Of hepatitis B vaccine or component 53. A parentlbrings her 4-month-oid infant to a well-baby ise for immunizations. The child is upto date with the immunization schedule. The nurse should prepare to ‘aminister Which immuncations to this infant? ‘A. Vericella, hepatitis B vaccine (HepB) 8. Diphtheria, tetanus, acelllar pertussis (DTaP); measles, mumps, rubella (MMR); inactiveted poliovirus vaccine (IPV) C._ MIR, Haemophilus influenzae type b (Hb), DTaP D. DBP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus Vaccine (RV) S54. The lini nurse is assessing a child who is scheduled to receive alive vis vaccine (immurization). What are the general contraindications asceciated with receiving lve virus vaccine? Select all that apply 4 | PoseThe child has symptoms of a col. The child had a previous anaphylactic reaction to the vaccine. The mother reports that the child is having intermittent episodes of diarthea. D._ The mother resorts that the chilé nas not had an appetite and has been fussy. The child has a disorder that caused severely deficient immune system. F. The mother renorts that the child has recently been exposed to an infectious disease: 55. The mother of a 6-year-old child arrives ata clinic because the child has been experiencing itchy, red, and ‘swollen eyes. The nurse notes a discharge from the eyes ‘and sends a culture to the laboratory for analysis. ‘Chlamydial conjunctivitis is diagnosed. On. the bad of this diagnosis, the nurse deterrrines that which requires further investigation? AR Possible trauma’ 8, Possible sexual abuse C. Presence of an alleray D. Presence of a respiratory infection 56. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? ‘A. "need to wash my hands frequently B. "Ineed to dean the aye ae prescribed.” C. "Itis okay to share towels and washcloths.” D. "Lneed to give the eye drops as prescrbed.” 57. The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? ‘AL “Lill clean up any spills from the diaoer with diluted alcohol “Lowi wash baby bottles, pacifiers in the dishwasher C. “Twill be sure to prepare foods that are high in calories and high in protein.” will be sure to wash my hands carefully before and after caring for my infant.” 58. Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. ipples, and > Monitor the child's weight. Frequent hand washing Is iportant. The child should avoid exposure to otfienillnesses. The child's immunization Schedule will need revision. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach), Feves, malaise, fatigue, weight loss, vomiting, end diarrhea are expected to ocaur and do notrequire special intervention. 59, The nurse provides home care instructions to the parents of a child hospitalized with pertussis who Isin the convalescent stage and is being prepared fer discharge. Which. statement by a parent indicates a need for further Instruction? ‘A "We need to encourage our child to drink fluids.” 8. "Coughing spells may be triggered by dust or smoke." C. “Vomiting may occur when cur child has coughing episodes." D. "We need to maintain droplet precautions and 3) quiet environment for atleast 2 weeks." 660, The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Kopii’s spots. On the basis of this documentation, which obsenatin Isexpecte? Pinpoint petechiae noted on both legs B. Whitsh vescles located across the chet C._Petechiae spots that are reddish and pinpdint on the soft palate D. Smal, blue-white spots with a red base found on the buccal mucosa 61. The parents ofa child recently diagnosed with cerebral palsy ask the nurse about the limitations ofthe disorder. The hurse responds by explaining that the limitations occur as a FES ytch gate sctogcal process? ‘Aninfectious disease ofthe central nervous system Bi. Animation of te bana 0 reat of oval illness C. A chrorie disabilty characterized by impaired muscle movement and posture . A congenital condition that results in moderate to severe intellectual disabilities 62. The nurse notes documentation thet a child's ‘ehibiting an inability to flex the leg_whien the thigh is flexed antecoriy at the hip. Which condtion does the rurse suspect? ‘A Meningitis 8. Spal cord injury C._ Intracranial bleeding Dip) Decreased ceretral blood flow 163. A mother arrives at the emergency department with her '-yearold child and states that the chid fell off a bunk bed. ‘Anead injury is suspected. The nurse crecks the child's airway status and assesses the chil for early and late signs of increased intracranial. pressure (ICP). Which is lete sign of increased ICP? ‘A. Nausea B Irtability| C Headache D, Bradycardia 64. The nurse is assigned to care for an 8-year-old child with a diagnosis of a basiar stull fracture. The nurse reviews the pediatridan's rescriptons and should contact, the pediatrician to question wich prescription? A. Obtein daily weight. B. Provide cear iquid inteke. €.Nasotracheal suction as needed. D, Maintain a patent intravenous lie. 65. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the chid hes exhibited sions of decerebrate posturing. On ‘assessment of the child, the nurse expects to note which characteristic ofthis type of posturing? Fleccid paraiysis of al extremities ‘Adduction of the arms at the shoulders Rigid extension and pronation ofthe arms and legs ‘Abnormal flexion of the upper extremities and extension and adduction ofthe lower extremties 66. A child. is diggnosed with Reye's syndrome. The nurse creates'a nursing care plen for the child and should include which intervention in the plan? (A. Assessing hezring loss 8 Montorirg urine output . Changing body position every 2 hours 1D/ Providing a quiet atmosphere win dimmed lighting 667. The nurse creates @ plan of care fora child at risk for tonic-donic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the childs bedside? ‘A. Emergency cart B, Tracheotomy set Padded tongue blade . Suctioningseaiipment and oxygen 68. A lumba puncture is performed on a chid suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) ic ‘obtained for analysis: The nurse reviews the results of the (CSF analyss and determines that which results would verty pope Pe 8 Ger CSF, elevated protein, and decreased glucose © Scien ese = 69. The nurse is planning care for a child with acute bacterial ‘meningitis. Based on the mode of transmission of this 5 | Pogeinfection, which precautionary intervention shouldbe included in the plan of care? ‘A. Maintain enteric precautions. 8. Maintain neutropenic precautions C._ No precautions are required as long as antibiotics nave been started. . Maintain respirator isolation prettions for at least 24 hours afte the initiation of ‘entibiotics. 70. An iéant with a diagnosis of hydrocephalus ic scheduled for surgery. Which isthe priorty nursing intervention inthe preoperative period? ‘A. Test the urine for protein. 8. Reposition the infant frequent, C. Provide a stimulating environment. ©. Assess blood pressure every 15 mirutes 71. The nurse i monitoring a chid fer bleeding after surgery for removal of a brain tumoc. The nurse checks the head dressing or the presence of blood and notes a colores drainage on the back ofthe dressing. Which ection should the nurse perform immediately? ‘A Notify the surgeon. B Reinforce the dressing. . Document the findings and continue to monitor ©. Circe the area of drainage and continue to monitor. 72. The mother of a 4-yearold child els the pediatric rurse thatthe child's abdomen seems to be swollen. During further assessment, the mother tells the rurse that the child is eating well and that the activiy level of the child is unchanged. The nurse, suspecting the possibilty of Wilms! tumor, should avoid which during the physical assessment? ‘A. Palpting the abdomen for a mass 8. Assessing the urine forthe presence of hematuria C. Monitoring the temperature forthe presence of fever . Monitoring the blood pressure for the presence of hypertension 73, The nurse provides a teaching session to the nursing saff regarding osteosarcoma. Which statement by amember of the nursing staff indicates a need for information? [AL "The femur is the most common site of this sarcoma.” “The chilé does not experierce pain atthe primary tumor site" “Limping, if a weight-bearing limb is affected, is @ clinical manifestation.” D. “The symptoms ofthe disease inthe early stage are aimost alvays attbuted to normal. growing pains” 74, The nurse analyzes the laboratory Values of a child with leukemia who is receiving. chemotherapy. The nurse notes that the platelet count s 19,500 mm (19.5 x 107/L). On the basis ofthis laboratory result, which intervention should the nurse indude in the plan of care? 'A. Intiate bleeding precautions. 8, Monitor closely for signs of infection. C. Monitor the temperature every 4 hours. 0. Initiate protective isolation precautions. 75, The nurse is monitoring a 3-year-old child for Ss and symptoms of creased intracranial pressure (ICP) after 2 Caniotomy. The nurse plans to monitor for which early sign ‘or symptom of inceased 10°? ‘Vomiting 8. Bulging anterior fontanel C. Increasing head circumference 0. Complaints ofa frontal headache 76. A ‘year-old chil ic admitted to the hospital fr abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easy. On physical examination, _ymphadenopethy and hepatosplenomegaly are’ noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines’ that which laboratory resut confirms the diagnosis? ‘A Lumbar puncture showing no blast cells 8. Bone a biopsy showing blast cals C. Platelet count of 350,000 mm (350 x 10°/L) 1, White blood cell count 4500 mn (4.5 x 10%/L) 77. k6-year-dld child with leukemia is hospitalized and receving combination chemotherapy. Laboratory results 8. indicate thet the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase fer the faWers.. Which response should the nurse provide to the ‘grandmother? ‘A. "Ihave a Vaseiin the utility room, and I will get it for 8. "Twill oot the vase and wash it well before you put the flowers init." © "The flowers from your gerden are beautiful, but should not be placed in the child's room at this time." D. "When you bring the flowers tothe room, place them on the bedside stand as far away from the chid as possible 7B. A diagnosis of Hodgkin's disease is suspected in a 12-yea-old child, Several diaghiostic studies are performed to determine the presence of this disease. Which diagnostic test result Will confirm the diagnosis of Hodgkins disease? ‘A. Elevated vanillyimandelic add urinary levels B._The presence ofbiast cells in te bone marrow C._ The presence of Epstsin-Borr virus in the blood D. The presence of Reed-Stemberg calls in the lymph nodes 79. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk fr infection? Select all that apply Maintain the child in a semiprivate room. Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the child's room wears a mask, E. Apply frm pressure to a needle-stick area for at least 10 minutes. 80. The nurse is performing an assessment on a AGyes-old chid suspected to have Hodgkin's disease, Which assessment findings are specifically characteristic ofthis disease? Select all that apply. ‘Abdominal pain Fever and malaise ‘Anorexia and weight loss Painful, enlerged inguinal ymph nodes Painless, firm, and movable adenopathy in the cervical area 81. The clinic nurse reviews the record of an infant and res that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse.reviews the assessment findings documented inithe record, knowing that whch sign_ most lkelyslel the mother to seek health care forthe infant? ‘A. Diarthea B, Projectile voriting, €. Regurgitation of feedings . Fouksmelling ribbon-lie stools S2qAilinfent has just returned to the nursing unit after ‘surgical repair of cleft lo on the right side. The nurse should place the infant in which best postion at this tme? ‘A Prone position 8. _Onthe stomach ©. Left lateral position D._ Right eteral postion ‘83 The nurse reviews the reeotd of a newborn infant and nates that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects tonote which most likely ign ofthis conditon documented in the recora? ‘A. Ineessant crying B. Coughing at righttime C. Choking with feedings D. Severe projectile vomiting 84. The nurse provides feeding instructions to a parent of an infent diagnesed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? ‘A. Provide less frequent, larger feedings. B. Burp the infant less frequently during feedings. C. Thin the feedings by adding water to the formula, D. Thicken the feedings by adding rice cereal to the poe mone 6 | Poseformula. 85, A chid is hosptalized because of persistent vomiting. ‘The nurse should monitor the child closely for which problem? AL Diarrhea 8. Metabolic acidosis C. Metabolic alkalosis D. Hyperactive bowel sounds 86, The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The. nurse moritors the infant, krowing that which s@Clnical manifestation associated with this dsorder? ‘A. Bile-stained fecal emesis 8. The passage of currant elly-ike stools C._ Failute to pass meconium stoo! inthe frst 24 hous after birth D. Sausage-shaped mass palpated if the upper right abdominal quadrant. 87. The nurse admits a child to the hospital weh a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the clés symptoms? ‘A. Watery diorthea 8, Projectle vomiting Increased urine output 0. Vomiting large emounts of bile 88, The nurse provides home care instructions tothe parents ofa child with eaiac disease. The nurse should teach the parents to include which food item inthe chil’s diet? 1. Rice 8, Oatmeal C. Rye toast D. Wheat bread 89. The nurse is preparing o care fora child with o diagnosis of intussusception. The nurse. reviews the child's record and expects 1D note which sign of this dlsorder documented? ‘A Watery diarthea 8. Ribbon like stoo's C Profuse projectile vomiting D. Bright red blood and mucus in the stoo's 90, Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select ll that appl. ‘A. Providing low-fat, well-balanced die. 8. Teaching the child effective hand-washing techniques. C._ Scheduling playtime in the prayreom with other children. . NotiVing the primary health Gare provider (PHCP) # jaundice is present. Instructing the parents to avoid administering medications unless prescribed. Arranging for indefinite home schooling because the dild will not be able to return to. school. 91, Aschool-2ge child with type 1 diabetes mellitus has Soccer practice and the school rurse provides instructs regardin how to prevent hypoalycemia during practice. Which should the schoo! nurse tellthe child to do? ‘A. Eat twice the amount normally eaten at lunchtime 8. Take half the mount of prescribed insulinon practice ays. Take the prescribed insulin at noontime rather than in the morning. D. at a small box of raisins or dFikia cup of orange juce before soccer practice. 92. The mother ofa 6-year old child who has type 1 diabetes melitus calls 2 cline nurse and tells the nurse thatthe child nas been sick. The mother reports that she checked the child's urine and it was postive for ketones. ‘The nurse should instruct the mether to take which acticn? [A Hold the next dose of insulin. 3. Come tothe clinic immedately. C. Encourage the child to dink iquids. . Administer an additional dose of regular insulin. 93, A pediatrician prescribes an intravenous (IV) sdution of 5% dextrose and falf-normal. saline (0.4596) with 40 mEq of petazsum chloride for a child with hypotonie dehydration. ‘The nurse performs which priority assessment before administering ths IV prescription? ‘A. Obtains a weight B. Takes the temperature C.Takes the blood pressure )DaChecks the amourt of urine output ‘9, An adolescent cient with type 1 diabetes metitus is ‘admitted tothe emergency. department for treatment of cliabetic ketoacidosis. Which assessment findings should the nurse expedtto note? "Ase Sweating ard tremors B Hungenand hypertension Gold, dammiy skn and irritabitty Fruity breath odor and decreasing level of consciousness ‘95)/Almother brings her 2-week-old infant to a cinic for a phenylketonuria rescrecning blood test, The test indicates 9 ‘serum phenylalenine level of 1 mgjdl. (60.5 memol/L). The nurse Teviens this result and makes which interpretaton? A. Its postive, Billbis nesetive. € Itisinconciusve D. It requires rescreening at age 6 weeks. 96. A child with type 1 diabetes melitus is brought to the emergency department by the mother, who states that the chid hes been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. ‘Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? ‘A. Potassium infusion 8. NPH insulin infusion C.5% dextrose infusion D. Normal saline infusion 97, Thesnurse has just administered ibuprofen to a cild with a temperature of 102° F (388 °C). The rurse should also take which action? ‘A. Withhnold oral fluids for 8 hours. B, Sponge the child with cold water. Plano administer salicylate in 4 hours. D, Remove excess clothing and blankets from the child 98. A child has fluid volume deficit. The nurse performs an ‘assessment and determines that the child is improving and the deficits resolving if which finding is noted? ‘A. The child has no tears. B. Urine specific gravity is 1.035. C. Capillary refills less than 2 seconds. , Urine output is less then 1 mL/ka/hr. 99. The nurse shoulé implement which interventions for 3 child older than 2 years with type 1. diebetes metus who hes a blood glucose level of 60 mg/dL (3.4 mmoV/)? Select all that apps ‘A. Administer regular insutin. Encourage the child to amrbulate {Give the child a teaspoon of honey. Provide electrolyte replacement therapy intrevencusly. \Weit'30 minutes and confirm the blood glucose reading. Prepare to administer alucagon subcutzneously i unconsdousness 100. The,nurs® provides instructions to the adolescent: regarding the administration of insulin. The nurse ‘should include which instruction? Rotate each insulin injection site on a weekly bass. Alternate between the thighs end tips for injections. ‘Check the biood glucose before administering insulin, ‘Avoid using the arms for injections because & is too dificult oF a procedure to perform. mone O9a> 7 | PogeTOPERANK * NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFE! RECALLS EXA\ NURSING P| CARE OF CLIENTS WITH PHYSIOLOGIC NOV 2023 Philippine Nurse. GENERAL INSTRUCTIONS: 1. This test questicnnaie contains 100 test questions 2. Stade nly one) box fr each queston or your answer sheets 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examines | WW ACADEMY RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY TION 14 (CE III ‘CHOSOCIAL ALTERATIONS (PART A) re éxamination Review ‘more boxes shaded will invalid your answer. ‘Sheet Sot 5. Write the subject ttle "NURSING PRACTICE III" on the bor. T. The nurse is reviewing the laboratory results oF 2 client diagnosed wth mute myeloma. Which would the nurse expect to note specially in this disorder? ‘A Increased calcum level 3. Increased vite blood calls C. Decreased blood urea nitrogen level D. Decreased number of plasma cel inthe bone 2. The nurse & creating a plan of care forthe cient with multpie myeloma and cludes which poy interventon inthe plan? 1A Encouraging fluids 8, Providing frequent oral care C. Coughing and deep breathing D. Monitring the ed bood cel count 3. Aciert is admitted tothe hospital with a suspected diagnosis of Hodgkin's dsezse. Which assessment finding would the nurse expect to note specifically the client? 1. Fatigue 3, Weakness Weight gain D. Enlarged lymph nodes 4. During the admission assessment ofa dient with advanced ovatan cancer, the nurse tecognizes which manifestation as typical of the disease? ’\ Dathes 3 Hypermenorthes Abnormal D. Abdominal distention 5. The nurse fs caring fora cent with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications ofa pesibe oncologcal fmergency? Select al that apply. ‘A. Fecal edema in the 8, Weight loss of 2 lb (9k) in 1 month C. Serum calcium level of 12 mg/dL (3.0 mmol/L) D. Serum sodium level of 136 ma/Al. (136 mmollL) E, Serum potassium level of 3.4 ma/d. (24 mmol/L) Numbness end tingling ofthe over extremities 6. Aciert who nas been receiving radiation therapy for badder cancer tel the nurse that itfeels as she is voidng through the vagina. The nurse interprets that the Cert may be experiencing which condition? ‘A. Rupture of the bladder B. The development ofa vesicovaginal fistula C._ Extreme stress caused by the dagnoss of cancer D. Altered perineal sensation asa side effect of radiation therapy 7. The nurse b conducting a history end monitoring laboratory values on a lent with multiple myeloma, What assessment findings should the nurse exoect to note? Select al that apply ‘A Pathelogial fracture B. Urinalysis positive for Bence Jones protein ‘C. Hemogiobin level of 15.5 g/L (55 mmol/L) D._ Calcium level oF 8.6 mg/dl (2.15 mmol.) E. Serum creatinine level of 2.0 maja. (176.6 mcrl/L) 8. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer i the client identfies which item as an associated risk factor? ‘A. Age younger than 50 years B. History of colorectal polyps CC Family history of colorectal cancer 1. Chronic ittammatory towe disease 9, The nusse § assessing the perineal viound in a dient: who has returned from the operating room following an abdominal perineal resection and notes Serosanquineous crainege rom the wound. Which hursing intervertion is most appropriate? ‘A. Clamp the surgical dai B, Change the dressing as prescribed . Nott the surgeon. . Remove and replace the perineal packing 10) The nue is reviewing the history of dient with bladder cancer. The nurse expects to note documentation of which ‘most common sgn or symptom ofthis type of cencer? A. Dysuria 8. Hematura C. Urgency on ination O. Frequency of urination 11. The nurse is conducting health screening for Which dents at greatest risk of developing ? -A25 year-old woman who runs 8A 36-year-old man who has asthma ‘A 70-year-old man who consumes excoss alcohol ‘A sedentary 65-year-old woman who smokes cigarettes nurse has given instructions toa dient returning after knee arthroscopy. Which statement by the ent indicates that the instructions are understood? soca resume regular exercise tomorrow." “Tcantteat food for the remainder ofthe day" "Lneed to stay off the leg entirely for the rest ofthe day” D._“Laeed 6 feporta fever oF sweling to my hearth care provide” nurse witnessed a vehicle hit a pedestrian. The Ie dazed and ties to get up. A leg appears fractured ‘nervention should the nurse take? Try to reduce the fracture manually. ‘Assist the victim to get up and walk to the sidewalk. Leave the victim fora few moments to call an ambulance. D._ Stay withthe victim and encourage him or her to remain stil. 14, Which cast care structions should the nurse provide to a dient who just hada plaster cast applied tothe right forearm? Select all that apply. ‘A. Keep the cast lean and dry. o> 1 | PogeAllow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. Expect tingling and numbness in the extremity. Use @ hair dryer set on a warm to hot setting to dry the cast. Use @ soft, padded object that wil fit undéF the cast to scratch the skin under the cast. 15, The nurse's evaluating a client in skeletal traction When evaluating the pin sites, the nurse would be most concerned with which finding? ‘A. Redness around the pin sites 8. Pain on palpation at the pin sites! C. Thick, yellow drainage from the pin sites D. Clear, watery drainage from the pin sites 16. The nurse's assessing the casted extremity of a client. Which sign i indicative of infection? |A. Dependent edema 8B. Diminished distal pulse C. Presence of a "bot spot" on the cast D. Coolness and pallor of the extremity 17. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The dlent is complainng of intense pain. The nurse elevates the lim, apples an ice bag, and administers an analgesic, with Ittle relief. Which problem may be causing this pain? ‘A Infection under the cast 8. The anxiety of the clent C. Impaired tssue perfusion D. The recent occurrence of the fracture 18. The nurse is admitting @ client weh multiple trauma injuries to the nursing unit. The client has a leg fracture and, had a plester cast applied. Which postion would be best for the casted leg? |. Elevated for 3 hours, then flat for 1 hour 3. Flat for 3 hours, then elevated for | hour C. Flat for 12 hours, then elevated for 12 hours D. Elevated on pillows contiruously for 24 to 48 hours 19. A dient iebeing discharged to home after applcation ofa plaster leg cast. Which statement indicates thatthe dient understands proper care ofthe cast? A. "Ineed to avoid geting the cast wet.” B. “I need to cover the casted leg with warm blankets.” C. “Teed to use my fingertips to lit and move my leg." D. “need te use something like a padded coat tanger end to scratch under the cast if it ches 20, A lent being measured for crutches asks the nurse wity the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? ‘A. All and further injury 8. Injury to the brechial plows nerves Shin breakdown in the area of the axilla D. Impaired renge of mation wie the client ambulates 21. The nurse's assessing the motor and sensory function of fan unconscious dent who sustained a head injury. The nurse should use which technique to test the dients peripheral response to pain? 'A Sternal rub 8. Nallbed pressure C. Pressure on the orbital rm D, Squeezing ofthe sternocteidomastoid muse 22. The nurse is caring for the clent with increased intracranial pressure asa result of a head injury? The nurse would note which trend in val sgns ifthe intracranial pressure is rising? 'A. Increasing temperature, increasing pulse, ‘nereasing respirations, decreasing blood pressure Increasing temperature, deceasing pulse, decreasing respiratons, increasing blood pressure Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood prescure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure 23. A dlient recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the cient doing which activity? ‘A. Blowing the nose Isometric exercises C. Coughing vigeroudy (D)Exhaling during reaostioning 24. A dient has dear uid leaking from the nose following a basilar skul fracture. Which. finding would alert the rurse that cerebrospinal fluid is present? ‘A. Fluid Is clear and tests negative for glucose. B.» Fid is grossly Hood in eppearance and tas 2 pH of ce Fu Clumpiitogether on the dressing and has a pH of D._ Fd spares int cance ngs an tests positive for alucose. 25. A client with a spinal cord injury is prone to experiencing autonomic dysrefiexa. The: nurse should include which ‘measures inthe plan of care to minimize the risk of ‘occurrence? Selet all that apply. ‘A. Keeping the linens wrinkle free under th cllent. 8B. Preventing unnecessary pressure on the lower limbs C. Limiting bladder catheterization to once every 12 hours D. Turning and repositioning the client at least every 2 hours E. Ensuring that the client has a bowel movement at least once a week 26, The nurse isevallating the neurological signs of a lent in spinal shock following. spinal cord injury. Which ‘observation indicates that spinal shock persists? ‘A. Hyperrefiexia B Positive reflexes CC Flactid paralysis D, Reflex emptying ofthe bladder 27, The nurse is caring for a cient who begins to experience seizure activity while in bed. Which actions shoud the nurse take? Selec al that apply. Loosening restrictive clothing. Restraining the lent’ limbs. Removing the pilow and raising padded side rll. Pesitioning the cient to the side, i possble, with the heed flexed forward. E. Keeping the Gurtaln around the dient and the roomiddor open so when help arrives they. can ‘quckly enter to assist. 28. The nurse is assigned to care for aclient with complete Fight-sided hemiparesis froma stroke (brain attack). WI characeristics ore essocated with this condltion? Select al that pp “The cent is apnasic. The cient has weakness on the' fight sie ofthe body. G_The Cent has complete bilateral peralysis ofthe arms and lege. D._Theidlient has weakness on the right side ofthe face E pope > ‘and tongue. The dient Fas lost the abiity to move the right farm but is able-to!Wwalk independenty. F. The client_hasl lost the abilty to ambulate indepéhdertly but is able to feed and bathe herself or himcelf without asstance. 29, The nurse has instructed the femly of a client with Stroke (Bran attack) who has homonymous hemianopsia atout measures to help the clent overcome the defict. Which statement suggests thatthe family understands the measures to use when caring for the cient? ‘A. "We need to discourage him from wearing eyeglasses. B. "Wie need to place objects in his impaired field of vision." "We need to approach him from the impaired feld of vision.” D. "We nead to remind him to turn his head to scan the lost visual fed.” 2 | Pose