Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008

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PSYCHIATRIC NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB, NurseReview.Org IS NOT RESPONSIBLE FOR ANY TYPOS, WRONG ANSWERS, WRONG RATIONALE, INCONSISTENCIES, ETC.. USE THIS AT YOUR DESGRESSION 1. Mental health is defined as: A. The ability to distinguish what is real from what is not. B. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. C. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation D. Absence of mental illness Answer: (B) A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. Mental health is a state of emotional and psychosocial well being. A mentally healthy individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits. A. This describes the ego function reality testing. C. This is the definition of Mental Health and Psychiatric Nursing. D. Mental health is not just the absence of mental illness. 2. Which of the following describes the role of a technician? A. Administers medications to a schizophrenic patient. B. The nurse feeds and bathes a catatonic client C. Coordinates diverse aspects of care rendered to the patient D. Disseminates information about alcohol and its effects. Answer: (A) Administers medications to a schizophrenic patient. Administration of medications and treatments, assessment, documentation are the activities of the nurse as a technician. B. Activities as a parent surrogate. C. Refers to the ward manager role. D. Role as a teacher. 3. Liza says, “Give me 10 minutes to recall the name of our college professor who failed many students in our anatomy class.” She is operating on her: A. Subconscious B. Conscious C. Unconscious D. Ego Answer: (A) Subconscious Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled spontaneously and voluntarily. B. This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in the environment. C. The largest potion of the mind that contains the memories of one’s past particularly the unpleasant. It is difficult to recall the unconscious content. D. The conscious self that deals and tests reality.

4. The superego is that part of the psyche that: A. Uses defensive function for protection. B. Is impulsive and without morals. C. Determines the circumstances before making decisions. D. The censoring portion of the mind. Answer: (D) The censoring portion of the mind. The critical censoring portion of one’s personality; the conscience. A. This refers to the ego function that protects itself from anything that threatens it.. B. The Id is composed of the untamed, primitive drives and impulses. C. This refers to the ego that acts as the moderator of the struggle between the id and the superego. 5. Primary level of prevention is exemplified by: A. Helping the client resume self care. B. Ensuring the safety of a suicidal client in the institution. C. Teaching the client stress management techniques D. Case finding and surveillance in the community Answer: (C) Teaching the client stress management techniques Primary level of prevention refers to the promotion of mental health and prevention of mental illness. This can be achieved by rendering health teachings such as modifying ones responses to stress. A. This is tertiary level of prevention that deals with rehabilitation. B and D. Secondary level of prevention which involves reduction of actual illness through early detection and treatment of illness. 6. Situation: In a home visit done by the nurse, she suspects that the wife and her child are victims of abuse. Which of the following is the most appropriate for the nurse to ask? A. “Are you being threatened or hurt by your partner? B. “Are you frightened of you partner” C. “Is something bothering you?” D. “What happens when you and your partner argue?” Answer: (A) “Are you being threatened or hurt by your partner? The nurse validates her observation by asking simple, direct question. This also shows empathy. B, C, and D are indirect questions which may not lead to the discussion of abuse. 7. The wife admits that she is a victim of abuse and opens up about her persistent distaste for sex. This sexual disorder is: A. Sexual desire disorder B. Sexual arousal Disorder C. Orgasm Disorder D. Sexual Pain Disorder Answer: (A) Sexual desire disorder Has little or no sexual desire or has distaste for sex. B. Failure to maintain the physiologic requirements for sexual intercourse. C. Persistent and recurrent inability to achieve an orgasm. D. Also called dyspareunia. Individuals with this disorder suffer genital pain before, during and after sexual intercourse.

8. What would be the best approach for a wife who is still living with her abusive husband? A. “Here’s the number of a crisis center that you can call for help .” B. “Its best to leave your husband.” C. “Did you discuss this with your family?” D. “ Why do you allow yourself to be treated this way” Answer: (A) “Here’s the number of a crisis center that you can call for help .” Protection is a priority concern in abuse. Help the victim to develop a plan to ensure safety. B. Do not give advice to leave the abuser. Making decisions for the victim further erodes her esteem. However discuss options available. C. The victim tends to isolate from friends and family. D. This is judgmental. Avoid in anyway implying that she is at fault. 9. Which comment about a 3 year old child if made by the parent may indicate child abuse? A. “Once my child is toilet trained, I can still expect her to have some" B. “When I tell my child to do something once, I don’t expect to have to tell" C. “My child is expected to try to do things such as, dress and feed.” D. “My 3 year old loves to say NO.” Answer: (B) “When I tell my child to do something once, I don’t expect to have to tell" Abusive parents tend to have unrealistic expectations on the child. A,B and C are realistic expectations on a 3 year old. 10. The primary nursing intervention for a victim of child abuse is: A. Assess the scope of the problem B. Analyze the family dynamics C. Ensure the safety of the victim D. Teach the victim coping skills Answer: (C) Ensure the safety of the victim The priority consideration is the safety of the victim. Attend to the physical injuries to ensure the physiologic safety and integrity of the child. Reporting suspected case of abuse may deter recurrence of abuse. A,B and D may be addressed later. 11. Situation: A 30 year old male employee frequently complains of low back pain that leads to frequent absences from work. Consultation and tests reveal negative results. The client has which somatoform disorder? A. Somatization Disorder B. Hypochondriaisis C. Conversion Disorder D. Somatoform Pain Disorder Answer: (D) Somatoform Pain Disorder This is characterized by severe and prolonged pain that causes significant distress. A. This is a chronic syndrome of somatic symptoms that cannot be explained medically and is associated with psychosocial distress. B. This is an unrealistic preoccupation with a fear of having a serious illness. C. Characterized

13. It is a voluntary expression of psychological conflicts C. 12. Failure to gratify these needs may result in anxiety. Physical symptoms are explained by organic causes B. satisfaction and security. D. Altered role performance D. Explanation of anxiety using the behavioral model. D. “I think you’re exaggerating things a little bit. A hypothalamic-pituitary-adrenal reaction to stress D. Medical treatment is not used because the disorder does not have a structural or organic basis. The following are appropriate nursing diagnosis for the client EXCEPT: A. Her knowledge of these various disorders is vital. Alteration in comfort.by alteration or loss in sensory or motor function resulting from a psychological conflict. Management entails a specific medical treatment Answer: (C) Expression of conflicts through bodily symptoms Bodily symptoms are used to handle conflicts. Conflict between id and superego C. Biomedical perspective of anxiety. A. “So tell me more about the pain” Answer: (A) “I know the feeling is real tests revealed negative results. Situation: A nurse may encounter children with mental disorders.” C. 14. “I know the feeling is real tests revealed negative results. Impaired social interaction Answer: (D) Impaired social interaction The client may not have difficulty in social exchange. B. The client will have discomfort due to pain. A. The client maladaptively uses body symptoms to manage anxiety. Manifestations do not have an organic basis.” Shows empathy and offers information. B. 15. C. C. Sullivan identified 2 types of needs. . pain C. The following statements describe somatoform disorders: A. A conditioned response to stressors Answer: (B) Conflict between id and superego Freud explains anxiety as due to opposing action drives between the id and the superego. This belittles the client’s feelings. Expression of conflicts through bodily symptoms D.” B. This is a demeaning statement. B. What would be the best response to the client’s repeated complaints of pain: A. The cues do not support this diagnosis. 16. “Try to forget this feeling and have activities to take it off your mind” D. C. Strives to gratify the needs for satisfaction and security B. A. Freud explains anxiety as: A. Ineffective individual coping B. D. This occurs unconsciously. . The client may fail to meet environmental expectations due to pain. Giving undue attention to the physical symptom reinforces the complaint.

remove the child from the classroom when disruptive behavior occurs Answer: (A) provide as much structure as possible for the child Decrease stimuli for behavior control thru an environment that is free of distractions. vandalism. D. Anxiety in school phobia is not due to being in school but due to separation from parents/caregivers so these interventions are not applicable. increase in appetite C. stealing. 17. Ritalin is the drug of choice for chidren with ADHD. encourage the child to engage in any play activity to dissipate energy D. C. provide as much structure as possible for the child B. increased attention span and concentration B. B. School phobia is usually treated by: A. lying and truancy. This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression. A. Answer: (D) Serious violations of age related norms. a calm non –confrontational approach and setting limit to time allotted for activities. Easy distractibility to external stimuli. Calmly explaining why attendance in school is necessary C. C. Returning the child to the school immediately with family support. This indicates that the classroom environment lacks structure. B. The child with conduct disorder will likely demonstrate: A. A 10 year old child has very limited vocabulary and interaction skills. Serious violations of age related norms. Ritualistic behaviors C. D. of 45. B. C. A. D. ignore the child’s overactivity. D. Exposure to the feared situation can help in overcoming anxiety.Q. These are noted among children with autistic disorder.When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder. bradycardia and diarrhea Answer: (A) increased attention span and concentration The medication has a paradoxic effect that decrease hyperactivity and impulsivity among children with ADHD. and C. This will not help the child overcome the fear 20. diarrhea and irritability. This will not help in relieving the anxiety due separation from a significant other. The child will not benefit from a lenient approach. Dissipate energy through safe activities. This is characteristic of attention deficit disorder. She has an I. C. She is diagnosed to have Mental retardation of this classification: . sleepiness and lethargy D. insomnia. B and C. Preference for inanimate objects. Allowing the parent to accompany the child in the classroom Answer: (A) Returning the child to the school immediately with family support. 19. The side effects of the following may be noted: A. Side effects of Ritalin include anorexia. B. 18. Allowing the child to enter the school before the other children D. a guide to remember is to: A.

angry outburst B. disobedience. B. disturbed relatedness. A. of below 20. giving reasonable compliments Answer: (A) overprotection of the child The child with mental retardation should not be overprotected but need protection from injury and the teasing of other children. A 5 year old boy is diagnosed to have autistic disorder. This refers to lack of choices or inability to mobilize one’s resources. A. use visuals and compliment them for motivation. Moderate D. a disruptive disorder among children. lying Answer: (B) intolerance to change. overprotection of the child B. altered family process D. assisting the parents set realistic goals D. Realistic expectations should be set and optimize their capability. Mild C. stealing. distractibility. The parents express apprehensions on their ability to care for their maladaptive child. intolerance to change. Profound B. 22. The following guidelines may be taught except: A.C. D. Refers to change in family relationship and function. altered parenting role C. and D Children with mental retardation have learning difficulty. The nurse teaches the parents of a mentally retarded child regarding her care. 21. disturbed relatedness.Q. C. C. Severe Answer: (C) Moderate The child with moderate mental retardation has an I. These are the manifestations of Conduct Disorder . truancy. stereotypes C. Which of the following manifestations may be noted in a client with autistic disorder? A. patience. argumentativeness. of 35-50 Profound Mental retardation has an I. aggression. Ineffective coping is the inability to form valid appraisal of the stressor or inability to use available resources 23. These manifestations are noted in Oppositional Defiant Disorder.A. Mild mental retardation 50-70 and Severe mental retardation has an I.Q. stereotypes These are manifestations of autistic disorder. The nurse identifies what nursing diagnosis: A. impulsiveness and overactivity D. This is reflected in the parent’s inability to care for the child.Q. They should be taught with patience and repetition. ineffective coping Answer: (B) altered parenting role Altered parenting role refers to the inability to create an environment that promotes optimum growth and development of the child. hopelessness B. start from simple to complex. routine and repetition C. of 20-35. These are manifestations of Attention Deficit Disorder D.

D. A. the use of symbols and the concept of time occur. The client admitted for alcohol detoxification develops increased tremors. Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms. hypertension and fever. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates: A. B. esophageal varices D. tolerance C. Angry outburst can be rechannelled through safe activities. withdrawal B. B. Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. 27. A. Sensory-motor stage (0-2 years) is the stage when the child uses the senses in learning about the self and the environment through exploration. Formal operations (2 till adulthood) is when abstract thinking and deductive reasoning develop. D. Intoxication refers to the behavioral changes that occur upon recent ingestion of a substance. Sensory motor stage B. Korsakoff’s syndrome C. The therapeutic approach in the care of an autistic child include the following EXCEPT: A. irritability. Pre-operational D. delirium tremens B. C.24. Concrete operations (7-12 years) when inductive reasoning develops. Concrete operations C. Formal operation Answer: (C) Pre-operational Pre-operational stage (2-7 years) is the stage when the use of language. 25. intoxication D. Situation : The nurse assigned in the detoxification unit attends to various patients with substance-related disorders. A. Provide safety measures D. B. Rearrange the environment to activate the child Answer: (D) Rearrange the environment to activate the child The child with autistic disorder does not want change. psychological dependence Answer: (B) tolerance tolerance refers to the increase in the amount of the substance to achieve the same effects. Maintaining a consistent environment is therapeutic. 26. The nurse should be alert for impending: A. Engage in diversionary activities when acting -out B. Acceptance enhances a trusting relationship. According to Piaget a 5 year old is in what stage of development: A. Provide an atmosphere of acceptance C. Ensure safety from self-destructive behaviors like head banging and hair pulling. Wernicke’s syndrome Answer: (A) delirium tremens .

Disulfiram (Antabuse) D. 29. D. Disulfiram is used as a deterrent in the use of alcohol. 28. Providing a quiet. Sedatives are used to relieve anxiety. a cannabinoid is manifested by sensation of slowed time.Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol B. The care for the client places priority to which of the following: A. This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B should be ensured. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. This is a complication of liver cirrhosis which may be secondary to alcoholism . C. with irritated nasal septum. A. agitated. Heroin B. A. 30. Elevation may indicate impending delirium tremens B. conjunctival redness. This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination. Monitoring his vital signs every hour B. marijuana Answer: (B) cocaine The manifestations indicate intoxication with cocaine. cocaine C. A client is admitted with needle tracts on his arm. Client needs quiet. social withdrawal. A. C. Narcan (Naloxone) C. impaired judgment and hallucinations. Intoxication with hallucinogen like LSD is manifested by grandiosity. Naltrexone (Revia) B. attention and the presence of papillary constriction. consistent and secure environment. stuporous and with pin point pupil will likely be managed with: A. B C. synesthesia and increase in vital signs D. dim room C. Methadone is used as a substitute in the withdrawal from heroine 31. a CNS stimulant. Methadone (Dolophine) Answer: (B) Narcan (Naloxone) Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. hallucinations. D. He is actively hallucinating. This is an opiate receptor blocker used to relieve the craving for heroine C. well lighted. LSD D. Adequate nutrition with sulpplement of Vit. D. Administering Librium as ordered Answer: (A) Monitoring his vital signs every hour Pulse and blood pressure are usually elevated during withdrawal. . Intoxication with Marijuana. Situation: An old woman was brought for evaluation due to the hospital for evaluation due to increasing forgetfulness and limitations in daily function. Intoxication with heroine is manifested by euphoria then impairment in judgment. Another client is brought to the emergency room by friends who state that he took something an hour ago. Encouraging adequate fluids and nutritious foods D.

but it is not the priority B. We will eat together” The therapeutic response by the nurse is: A. agnosia D. D. She is manifesting: A. Amnesia is loss of memory. “Oh no.” D. This is not a helpful approach because of the short term memory of the client.” B..” D. I will wait for my husband. amnesia Answer: (C) agnosia This is the inability to recognize objects.” The client should be reoriented to reality and be focused on the here and now. Let me serve you your breakfast. 35. Your mother does not mean it. “Have you tried discussing this with your mother?” C. “This must be difficult for you and your mother. remains in a safe and secure environment D. Patient is allowed to reminisce but it is not the priority.” B. “Your husband is dead. B. will reminisce to decrease isolation C. This response does not encourage verbalization of feelings. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently 34. C.” This reflecting the feeling of the daughter that shows empathy. A. Giving advise does not encourage verbalization.” Answer: (C) “This must be difficult for you and your mother. D. It’s time to eat. The cognitive limitation of the client makes the client incapable of giving explanation. Let me serve you your breakfast. Dementia unlike delirium is characterized by: . She tearfully tells the nurse “I can’t take it when she accuses me of stealing her things. ”Don’t take it personally.” Which response by the nurse will be most therapeutic? A. Apraxia is the inability to execute motor activities despite intact comprehension. aphasia C. D. 32. A and D. independently performs self care Answer: (C) remains in a safe and secure environment Safety is a priority consideration as the client’s cognitive ability deteriorates.. This indicates a pompous response. She says to the nurse who offers her breakfast. Aphasia is the loss of ability to use or understand words. 33. A is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs. “Next time ask your mother where her things were last seen. B. “What made you say that your husband is alive? Answer: (A) “Your husband is dead. “You’re going to have to wait a long time.The daughter revealed that the client used her toothbrush to comb her hair. receives adequate nutrition and hydration B. B. apraxia B. “I’ve told you several times that he is dead. The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client: A.” C.

A. insidious onset C. Limits should be set on attempts to lose more weight. fluid volume deficit C. B. Situation: A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration secondary to starvation. 36. Starvation should not be encouraged. altered nutrition less than body requirements D. 38. The client with anorexia nervosa is preoccupied with losing weight due to disturbed body image. She attends ward activities. What is the best intervention to teach the client when she feels the need to starve? A. altered family process Answer: (B) fluid volume deficit Fluid volume deficit is the priority over altered nutrition (A) since the situation indicates that the client is dehydrated. A and D are psychosocial needs of a client with anorexia nervosa but they are not the priority. Answer: (B) Weight gain Weight gain is the best indication of the client’s improvement. Do a short term exercise until the urge passes C. Which of the following nursing diagnoses will be given priority for the client? A. The goal is for the client to gain 1-2 pounds per week. She has a more realistic self concept. Physical safety is a priority. The client may have a domineering mother which causes the client to feel ambivalent. sensory perceptual change Answer: (B) insidious onset Dementia has a gradual onset and progressive deterioration. . A. clouding of consciousness D. (D) Body image is a factor in anorexia nervosa but it is not an indicator for improvement. The client with anorexia nervosa is improving if: A. D. A. Talking out feelings with the nurse is an adaptive coping. a life threatening situation exists. Call her mother on the phone and tell her how she feels Answer: (C) Approach the nurse and talk out her feelings The client with anorexia nervosa uses starvation as a way of managing anxiety. Weight gain C.C and D are all characteristics of delirium. Approach the nurse and talk out her feelings D. 37. D. (C) Attending an activity does not indicate improvement in nutritional state. slurred speech B. Without adequate nutrition. She eats meals in the dining room. altered self-image B. B. It causes pronounced memory and cognitive disturbances. Allow her to starve to relieve her anxiety B. The client will not discuss her feelings with her mother. (A)The client may purge after eating.

agoraphobia B. The client is often ashamed of her eating behavior.C and D promote a therapeutic relationship 42. Discussion should focus on feelings. A. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. Patient will learn problem solving skills B. B. D. A nursing diagnosis for bulimia nervosa is powerlessness related to feeling not in control of eating habits. Establish an atmosphere of trust B. Help patients identify feelings associated with binge-purge behavior D. 41. Claustrophobia D. have peculiar food handling patterns D. have threatened self-esteem Answer: (A) have episodic binge eating and purging Bulimia is characterized by binge eating which is characterized by taking in a large amount of food over a short period of time. have repeated attempts to stabilize their weight C. Patient will verbalize how to set limits on others. B and C are characteristics of a client with anorexia nervosa D. Answer: (A) Patient will learn problem solving skills if the client learns problem solving skills she will gain a sense of control over her life. social phobia C. Agoraphobia is fear of open space or being a situation where escape is difficult. Discuss their eating behavior. (B) Anxiety is caused by powerlessness. xenophobia Answer: (C) Claustrophobia Claustrophobia is fear of closed space. . Patient will perform self care activities daily. In the management of bulimic patients. the following nursing interventions will promote a therapeutic relationship EXCEPT: A.39. Teach patient about bulimia nervosa Answer: (B) Discuss their eating behavior. C. The goal for this problem is: A. Low esteem is noted in both eating disorders 40. Situation: A 35 year old male has intense fear of riding an elevator.” This has affected his studies The client is suffering from: A. have episodic binge eating and purging B. A. D. Patient will have decreased symptoms of anxiety. C. (C) Performing self care activities will not decrease ones powerlessness (D) Setting limits to control imposed by others is a necessary skill but problem solving skill is the priority. He claims “ As if I will die inside. Xenophobia is fear of strangers. The characteristic manifestation that will differentiate bulimia nervosa from anorexia nervosa is that bulimic individuals A.

45. Establish trust through a consistent approach. Valium causes dry mouth so the client must increase her fluid intake. Allow expression of the client’s fears but he should focus on other productive activities as well. Which is the desired outcome in conducting desensitization: A. The client will socialize with others willingly D. There are no restrictions in activities. Any beverage like coffee may be taken Answer: (A) Avoid taking CNS depressant like alcohol. The nurse develops a countertransference reaction. Situation: A 20 year old college student is admitted to the medical ward because of sudden onset of paralysis of both legs. The client will overcome his disabling fear by gradual exposure to the feared object. Valium is a CNS depressant. D. Extensive examination revealed no physical basis for the complaint. Which of the following should be included in the health teachings among clients receiving Valium: A. B. Accept her fears without criticizing. C. 44. The client will be able to overcome his disabling fear. C. A. Avoid taking CNS depressant like alcohol. B. B. C. D. D.43. Confronting the client about discrepancies in verbal or non-verbal behavior D. Stimulants must not be taken by the client because it can decrease the effect of Valium. Answer: (D) The client will be able to overcome his disabling fear. These are therapeutic approaches. Countertransference is an emotional reaction of the nurse on the client based on her unconscious needs and conflicts. Limit fluid intake. C. These are not the initial interventions. The client should be taught to avoid activities that require alertness. This is evidenced by: A. B and C. The nurse plans intervention based on which correct statement about conversion disorder? . The client will voluntarily attend group therapy in the social hall. Answer: (D) Accept her fears without criticizing. Assist him to find meaning to his feelings in relation to his past. Focusing on the feelings of the client.B and C are not the desired outcome of desensitization. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. The client feels angry towards the nurse who resembles his mother. Taking it with other CNS depressants like alcohol. C. The client cannot control her fears although the client knows its silly and can joke about it. potentiates its effect. 47. Revealing personal information to the client B. The client verbalize his fears about the situation B. Answer: (A) Revealing personal information to the client A. D. 46. Encourage to verbalize his fears as much as he wants. A. B and C. Initial intervention for the client should be to: A.

A. B. Nina reveals that the boyfriend has been pressuring her to engage in premarital sex. 48. A. It is a deliberate effort to handle upsetting events C. This is not therapeutic because it confronts the underlying cause. Unlike psychophysiologic disorder Linda may be best managed with: A. Malingering is different from somatoform disorder because the former: A. “It sounds like this problem is related to your paralysis. C. Both have primary gains. The central force of the client’s condition is anxiety. “I can refer you to a spiritual counselor if you like. milieu therapy C. The condition occurs unconsciously. The conversion symptom has symbolic meaning to the client D. stress management techniques D.A. He learns to verbalize his feelings and concerns D. . His symptoms are replaced by indifference to his feelings B. D. The client will experience high level of anxiety in response to the paralysis. C. “How do you feel about being pressured into sex by your boyfriend?” Answer: (D) “How do you feel about being pressured into sex by your boyfriend?” Focusing on expression of feelings is therapeutic. D. 50. The client is not distressed by the lost or altered body function. This disorder is not supported by organic pathology so no medical regimen is required.” D. A confrontational approach will be beneficial for the client. Both disorders do not have an organic or structural basis. Has evidence of an organic basis. Answer: (C) The conversion symptom has symbolic meaning to the client the client uses body symptoms to relieve anxiety. He participates in diversionary activities. Milieu therapy and psychotherapy may be used a therapeutic modalities but these are not the best. C. 49. This is a characteristic of somatoform disorder. Stress is expressed through physical symptoms.” C. Answer: (B) It is a deliberate effort to handle upsetting events Malingering is a conscious simulation of an illness while somatoform disorder occurs unconscious.” B. Giving advice is not therapeutic. A. This is not therapeutic because the nurse passes the responsibility to the counselor. Which is the best indicator of success in the long term management of the client? A. D. “You shouldn’t allow anyone to pressure you into sex. A. He states that his behavior is irrational. The client should not be confronted by the underlying cause of his condition because this can aggravate the client’s anxiety. B. C. medical regimen B. 51. Gratification from the environment are obtained. psychotherapy Answer: (C) stress management techniques Stree management techniques is the best management of somatoform disorder because the disorder is related to stress and it does not have a medical basis. The symptoms are conscious effort to control anxiety B. B. The most therapeutic response by the nurse is: A. B and D.

Impaired social interaction related to repressed anger. The client said “I can’t even take care of my baby. Remembering both positive and negative aspects of the deceased love one signals successful mourning. C. The cues do not indicate inability to use coping resources. “I feel envious of mothers who have toddlers” B. 53. Situation: A young woman is brought to the emergency room appearing depressed. Which is the highest priority in the post ECT care? . Expressing feelings openly is acceptable. Prozac B. D. A sense of worthlessness may accompany depression. A. decreased ability to transmit/process symbols. A. 52. D. Ineffective individual coping related to loss. Participation in activities diverts the client’s attention away from his bodily concerns but this is not the best indicator of success. Parnate D. The nurse learned that her child died a year ago due to an accident. Impaired verbal communication related to inadequate social skills. “I often find myself thinking of how I could have prevented the death. Zyprexa Answer: (D) Zyprexa This is an antipsychotic. This is a MAOI antidepressant. This indicates the stage of depression in the grieving process.B and D are not relevant. The client is encouraged to talk about his feelings and concerns instead of using body symptoms to manage his stressors. not as irrational. nor insufficient quality of social exchange 54. The following medications will likely be prescribed for the client EXCEPT: A. B. 55. I’m good for nothing. This antidepressant belongs to the Tricyclic group. This is a SSRI antidepressant. unsuccessful use of denial is dysfunctional. The statement of the woman that supports this diagnosis is: A. B. Help the client recognize that his physical symptoms occur because of or are exacerbated by specific stressor. C. Answer: (C) Low esteem related to failure in role performance This indicates the client’s negative self evaluation.” D. This indicates acknowledgement of the loss. The initial nursing diagnosis is dysfunctional grieving. Answer: (B) “I haven’t been able to open the door and go into my baby’s room “ This indicates denial. Low esteem related to failure in role performance D. A. “I watch other toddlers and think about their play activities and I cry. Tofranil C. This defense is adaptive as an initial reaction to loss but an extended. The client is encouraged to acknowledge feelings rather than being indifferent to her feelings. C. “I haven’t been able to open the door and go into my baby’s room “ C. A.” Which is the appropriate nursing diagnosis? A. B.Answer: (C) He learns to verbalize his feelings and concerns C.

Confusion and disorientation are side effects of ECT but these are not the highest priority. . Provide the client with extra time for one on one sessions D. 57. repeat verbal instructions as often as needed C. In ensuring a therapeutic milieu. Assigning a staff to be with the client at all times is not realistic. Clear. D. painting C. table tennis B. An activity appropriate for the client is: A. He is demanding. B. Suggest that the client take a leading role in the social activities C. B. A and C. A consistent firm approach is appropriate. 58. cleaning Answer: (D) cleaning The client’s excess energy can be rechanelled through physical activities that are not competitive like cleaning. This is not therapeutic because the client tends to control and dominate others. The client is arrogant and manipulative. The manic client tend to externalize hostile feelings. Bargaining should not be allowed. Limits are set for interaction time. Document the client’s response to the treatment Answer: (B) Monitor respiratory status A side effect of ECT which is life threatening is respiratory arrest. A. Nurses set limit as needed. chess D.A. C. Observe for confusion B. Situation: A 27 year old writer is admitted for the second time accompanied by his wife. C. 56. Agree on a consistent approach among the staff assigned to the client. concise directions are given because of the distractibility of the client but this is not the priority. Allow the client to negotiate the plan of care Answer: (A) Agree on a consistent approach among the staff assigned to the client. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Tennis is a competitive activity which can stimulate the client. A quiet environment and consistent and firm limits should be set to ensure safety. allow the client to get out feelings to relieve tension D. This is also a way to dissipate tension. Initially the nurse should plan this for a manic client: A. assign a staff to be with the client at all times to help maintain control Answer: (A) set realistic limits to the client’s behavior The manic client is hyperactive and may engage in injurious activities. however only non-destructive methods of expression should be allowed D. place and person D. Reorient to time. arrogant talked fast and hyperactive. Monitor respiratory status C. Allowing the client to negotiate may reinforce manipulative behavior. B. set realistic limits to the client’s behavior B. the nurse does one of the following: A.

What should the nurse do first: A. Depression is a painful stage where the individual mourns for what was lost. This may either be directed to God. Denial C. “That is a negative attitude. B. Depression B. 61. “ It isn’t fair that an innocent like you will suffer from AIDS. polyuria and polydipsia. whose husband died one year ago due to AIDS. Give the client Cogentin C. Using an authoritarian. The common side effects of Lithium are fine hand tremors. 60. Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger. This is a threatening approach. “Why me? How could God do this to me?” This reaction is one of: A. A client on Lithium has diarrhea and vomiting. D.” B. How can I best help you?” .59. nausea. has just been told that she has AIDS. C.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss. B. In bargaining the individual holds out hope for additional alternatives to forestall the loss. the deceased or displaced on others. Reassure the client that these are common side effects of lithium therapy D. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings The client has the right to be free from unnecessary restraints. Hold the next dose and obtain an order for a stat serum lithium level Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Diarrhea and vomiting are manifestations of Lithium toxicity. The nurse’s therapeutic response is: A. Putting the client in a seclusion room D.” C. Recognize this as a drug interaction B. evidenced by the statement “If only…” 62. bargaining Answer: (C) anger Anger is experienced as reality sets in. C and D. The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A. A. Pamela says to the nurse. confrontational approach C. “I will refer you to a clergy who can help you understand what is happening to you. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger. it can’t be true. Situation: A widow age 28. The manifestations are not due to drug interaction. A. anger D. ”It must really be frustrating for you. Denial is the first stage of the grieving process evidenced by the statement “No. The next dose of lithium should be withheld and test is done to validate the observation. B. Taking a directive role in verbalizing feelings B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics.” D.

the statement and non verbal cue of the client indicate suicide. The client has which of the following developmental focus: A. B. Hopelessness Answer: (B) suicidal ideation The client’s statement is a verbal cue of suicidal ideation not anxiety. Remove all potentially harmful items from the client’s room. The nurse asks her “What are you thinking about?” This communication technique is: A.K. Note the client’s capabilities to increase self esteem. 66. A helping relationship can be forged by showing empathy and concern. reflecting D. Allow the client to express feelings of hopelessness. 63. Allowing patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. How can I best help you?” This response reflects the pain due to loss. Parental and societal responsibilities. This statement passes judgment on the client. B. Increasing self esteem is an intervention for depressed clients bur not specifically for suicide. C.Answer: (D) ”It must really be frustrating for you. A. 64. validating C. A. to work as nurse. The client says to the nurse ” Pray for me” and entrusts her wedding ring to the nurse. anxiety B. Major depression D. B. This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts. Establishing relationship with the opposite sex and career planning. 65. This is not therapeutic since it passes the buck or responsibility to the clergy. One morning the nurse sees the client in a depressed mood. While suicide is common among clients with major depression. focusing B. Which of the following interventions should be prioritized in the care of the suicidal client? A.B and C are all therapeutic techniques but these are not exemplified by the nurse’s statement. C. Set a “no suicide” contract with the client. giving broad opening Answer: (D) giving broad opening Broad opening technique allows the client to take the initiative in introducing the topic. Answer: (A) Remove all potentially harmful items from the client’s room. The nurse knows that this may signal which of the following: A. Accessibility of the means of suicide increases the lethality. Hopelessness indicates no alternatives available and may lead to suicide. . this occurs when their depression starts to lift. D. suicidal ideation C. Situation: A 14 year old male was admitted to a medical ward due to bronchial asthma after learning that his mother was leaving soon for U.

safety. D. perfectionist D. The masochistic. Developing initial commitments and collaboration in work Answer: (A) Establishing relationship with the opposite sex and career planning. A. D. The client belongs to the adolescent stage. learning or working environment. D. masochistic Answer: (B) dependent A client with dependent personality is predisposed to develop asthma. occupational and social roles. This is not congruent with therapeutic milieu. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. The personality type of Ryan is: A. norms. B. A. D. The adolescent emancipates himself from the family and decides what career to pursue. A permissive and congenial environment Answer: (C) A living. A cognitive approach to change behavior C. establishment of a safe and congenial family environment and building of one’s lifework. The stage of young adulthood is concerned with development of intimate relationship with the opposite sex. limit setting. Help her recognize that her physical condition has an emotional component Answer: (C) Place in semi-fowlers position and render O2 inhalation as ordered . 67. B. self sacrificing type are prone to develop rheumatoid arthritis. The nurse ensures a therapeutic environment for the client. This reflects school age which is concerned with the pursuit of knowledge and skills to deal with the environment both in the present and in the future. C. A therapeutic milieu refers to a broad conceptual approach in which all aspects of the environment are channeled to provide a therapeutic environment for the client. C. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. The six environmental elements include structure. what set of friends to have and what value system to uphold. The conforming non-assertive client is predisposed to develop hypertension because of the tendency to repress rage. balance and unit modification. This refers to the middle adulthood stage concerned with transmitting his values to the next generation to ensure his immortality through the perpetuation of his culture. dependent C. 69. D. Place in semi-fowlers position and render O2 inhalation as ordered D. Establishing ones sense of competence in school. conforming B. 68. Which of the following best describes a therapeutic milieu? A. Included as priority of care for the client will be: A. Divert attention to ward activities C. learning or working environment. A living. Encourage verbalization of concerns instead of demonstrating them through the body B. A therapy that rewards adaptive behavior B.C. The adolescent establishes his sense of identity by making decisions regarding familial. The perfectionist and compulsive tend to develop migraine.

It is the sexual pleasure derived from inanimate objects.B and D are important considerations but these are not the priority. It is the pleasure derived from being humiliated and made to suffer C. B. D. D. these are not the priority. Knowledge about sexuality. “Aren’t you glad that you’re going home soon?” Answer: (C) “You seem to have concerns about going home. B. B. Experience in dealing with clients with sexual problems C. It is the desire to live or involve in reactions of the opposite sex Answer: (D) It is the desire to live or involve in reactions of the opposite sex Gender identity disorder is a strong and persistent desire to be the other sex. “You are much better than when you were admitted so there’s no reason to worry. The client is concerned about his coming discharge. A. This is fetishism. A. manifested by being unusually sad. Which is the most therapeutic approach by the nurse? A. 70. Sexual Desire B.. Comfort with one’s sexuality D. The sexual response cycle in which the sexual interest continues to build: A. Orgasm . C. Which of the following statements is true for gender identity disorder? A. This close ended question does not encourage verbalization of feelings. It is the pleasure of shocking the victim with exposure of the genitalia D.” . it does not focus on expression of feelings. B. The client has physical symptom that is adversely affected by psychological factors. A. This can happen only when the nurse has reconciled and accepted her feelings and beliefs related to sexuality. Helping the client connect the physical symptoms with the emotional problems can be done when the client is ready. 71. A and B. Showing empathy can encourage the client to talk which is important as an alternative more adaptive way of coping with stressors.” D. 73. While this technique explores plans after discharge.” B. “You seem to have concerns about going home. Verbalization of feelings in a non threatening environment and involvement in relaxing activities are adaptive way of dealing with stressors. Giving false reassurance is not therapeutic. This statement reflects how the client feels. This refers to masochism. However. empathetic and non-judgmental to patients who disclose concerns regarding sexuality. Failure to address the medical condition of the client may be a life threat. Ability to communicate effectively Answer: (C) Comfort with one’s sexuality The nurse must be accepting. This describes exhibitionism. 72.Since psychopysiologic disorder has organic basis. priority intervention is directed towards disease-specific management. Situation: The nurse may encounter clients with concerns on sexuality. “What would you like to do now that you’re about to go home?” C. The most basic factor in the intervention with clients in the area of sexuality is: A. Sexual arousal C.

” The most therapeutic response by the nurse is: A. The nurse asks a client to roll up his sleeves so she can take his blood pressure. Putting up your sleeve is fine. Sexual Arousal Disorder C. Orgasm refers to the peak of the sexual response where the female has vaginal contractions for the female and ejaculatory contractions for the male. help the client identify the stressor or the true object of hostility. during or after sexual intercourse.D. Pacing is a tension relieving measure for an agitated client. You need to stop that behavior now. A. C. matter of fact way. The inability to maintain the physiologic requirements in sexual intercourse is: A. Which of the following statements is most appropriate to make to this patient? A. Threatening the client is not therapeutic. Resolution Answer: (B) Sexual arousal Sexual arousal or excitement refers to attaining and maintaining the physiologic requirements for sexual intercourse. The client replies “If you want I can go naked for you. Resolution is the final phase of the sexual response in which the organs and the body systems gradually return to the unaroused state. Sexual Desire Disorder refers to the persistent and recurrent lack of desire or willingness for sexual intercourse. C. You will need to be restrained if you do not change your behavior. D. Orgasm Disorder is the inability to complete the sexual response cycle because of the inability to achieve an orgasm. Situation: Knowledge and skills in the care of violent clients is vital in the psychiatric unit. “I only need access to your arm. A and B. interest or willingness for sexual stimulation. C. pacing up and down the hallway and making aggressive remarks. 75. Sexual Desire Disorder B. This helps reveal unresolved issues so that they may be confronted. These responses are not therapeutic because they are challenging and rejecting. Putting up your sleeve is fine. Sexual Pain Disorder is characterized by genital pain before. Sexual Pain disorder Answer: (B) Sexual Arousal Disorder This describes sexual arousal disorder. 74. C. Orgasm Disorder D.” The nurse needs to deal with the client with sexually connotative behavior in a casual. D. “I will report you to the guard if you don’t control yourself.” D. D. What is causing you to become agitated? B. 76.” Answer: (D) “I only need access to your arm. “You wouldn’t be the first that I will see naked. C. This is a threatening statement that can heighten the client’s tension.” B. Seclusion is used when less restrictive measures have failed.” C. Answer: (A) What is causing you to become agitated? In a non-violent aggressive behavior. . “You’re attractive but I’m not interested. Sexual Desire refers to the ability. You will need to be placed in seclusion. A nurse observes that a client with a potential for violence is agitated. D. A. B.

The nurse exemplifies awareness of the rights of a client whose anger is escalating by: A.77. B and C are appropriate approaches during the escalation phase of aggression. Answer: (D) The staff carried out less restrictive measures but were unsuccessful. Applying mechanical restraints Answer: (A) Taking a directive role in verbalizing feelings Taking a directive role in the client’s verbalization of feelings can deescalate the client’s anger. soft spoken nurse may feel intimidated by the angry patient. C and D. 79. A. aggressive client should be assigned to the most experienced nurse. He was restrained after his behavior can no longer be controlled by the staff. 80. a soft spoken nurse Answer: (B) A mature experienced nurse The unstable. When verbal and psychopharmacologic interventions are not adequate to handle the aggressiveness. Initiate confinement measures Answer: (D) Initiate confinement measures The proper procedure for dealing with harmful behavior is to first try to calm patient verbally. Which of these documentations indicates the safeguarding of the patient’s rights? A. 78. A. Assist the client to an area that is quiet D. A confrontational approach can be threatening and adds to the client’s tension. Which approach is least helpful for the client at this time? A. A timid nurse B. seclusion or restraints may be applicable. Maintain a safe distance from the client C. C. This documentation indicates that the client has been placed on restraints after the least restrictive measures failed in containing the client’s violent behavior. Taking a directive role in verbalizing feelings B. The patient’s rights were explained to him. an inexperienced nurse D. confrontational approach C. The nurse observes that the client’s anger is escalating. C and D. The nurse closely observes the client who has been displaying aggressive behavior. There was a doctor’s order for restraints/seclusion B. Use of restraints and isolation may be required if less restrictive interventions are unsuccessful. The staff observed confidentiality D. B. The charge nurse of a psychiatric unit is planning the client assignment for the day. inexperienced. A mature experienced nurse C. A shy. The most appropriate staff to be assigned to a client with a potential for violence is which of the following: A. The staff carried out less restrictive measures but were unsuccessful. Acknowledge the client’s behavior B. The client jumps up and throws a chair out of the window. . . Using an authoritarian. Putting the client in a seclusion room D.

orderliness and need for control . Individuals with histrionic have excessive emotionality. B. hypervigilance and coldness D. recover with therapeutic intervention B. Preoccupation with perfectionism. strong dependency needs and impulsive behavior B. reaction formation C. This disorder is manifested by life-long patterns of behavior. D. and attention-seeking behaviors. Which personality disorder is he likely to have? A. sensitivity to rejection and criticism C. Clients with personality disorder will most likely: A. The client with this disorder will not likely present himself for treatment unless something has gone wrong in his life so he may not recover from therapeutic intervention. Histrionic D. Antisocial Answer: (D) Antisocial These are the characteristics of an individual with antisocial personality. Suspicious. Denial is refusal to accept a painful reality. projection Answer: (B) reaction formation Reaction formation is the adoption of behavior or feelings that are exactly opposite of one’s true emotions. Projection is attributing of one’s behaviors and feelings to another person. A teenage girl is diagnosed to have borderline personality disorder. Narcissistic personality disorder is characterized by grandiosity and a need for constant admiration from others. B. respond to antianxiety medication C. Narcissistic B. C. 82. Seek treatment willingly from some personally distressing symptoms Answer: (C) manifest enduring patterns of inflexible behaviors Personality disorders are characterized by inflexible traits and characteristics that are lifelong. A and D. Paranoid C. is demonstrating the use of: A. rationalization D. A client tends to be insensitive to others. engages in abusive behaviors and does not have a sense of remorse. Which manifestations support the diagnosis? A. Rationalization is attempting to justify one’s behavior by presenting reasons that sounds logical. Individuals with paranoid personality demonstrate a pattern of distrust and suspiciousness and interprets others motives as threatening. Lack of self esteem. 83. manifest enduring patterns of inflexible behaviors D. Medications are generally not recommended for personality disorders.81. A. 84. inadequacy. denial B. social withdrawal. A. The client joins a support group and frequently preaches against abuse. C. Situation: Clients with personality disorders have difficulties in their social and occupational functions.

despair Answer: (D) Ego integrity vs. stagnation D. The client says “ the NBI is out to get me. Flexibility and bargaining are not therapeutic in dealing with a manipulative client. Ensuring she adheres to certain restrictions Answer: (D) Ensuring she adheres to certain restrictions The client is manipulative. This focuses on the self rather than others 88. to deal with feelings and thoughts that are not acceptable C. Clients who are suspicious primarily use projection for which purpose: A. This describes the avoidant personality. Industry vs.” The nurse’s best response is: .Answer: (A) Lack of self esteem. mistrust B. to show resentment towards others D. Giving medications to prevent acting out C. is admitted in the ward because of bizarre behaviors. This is not part of the care plan. expectations. strong dependency needs and impulsive behavior These are the characteristics of client with borderline personality. It is a productive and creative stage. C. This is not true in all instances of projection C and D. despair The client belongs to the middle adulthood stage (30 to 65 yrs. 87.) is concerned with gratification of oral needs (B) School Age child (6 – 12 yrs. Ego integrity vs. He is given a diagnosis of schizophrenia paranoid type. B. These are the characteristics of a client with paranoid personality D. A. Limit setting and flexibility in schedule B. manipulate others Answer: (B) to deal with feelings and thoughts that are not acceptable Projection is a defense mechanism where one attributes ones feelings and inadequacies to others to reduce anxiety. Limits should be firmly and consistently implemented. Generativity vs. (A) Infancy stage (0 – 18 mos.) The developmental task generativity is characterized by concern and care for others. The client must be informed about the policies. Interaction with other clients are allowed but the client should be observed and given limits in her attempt to manipulate and dominate others. C. rules and regulation upon admission. The plan of care for clients with borderline personality should include: A. 86. There is no specific medication prescribed for this condition. This describes the obsessive compulsive personality 85. inferiority C. Trust vs. The client should have achieved the developmental task of: A. Situation: A 42 year old male client.) is characterized by acquisition of school competencies and social skills (C) Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future. B. deny reality B. A. Restricting her from other clients D.

” Answer: (C) “I don’t know anything about that. A. “I don’t know anything about that. Internal Answer: (B) Adventitious Adventitious crisis is a crisis involving a traumatic event. Counterttransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. He is likely manifesting: A. Situational B. wormlike movement of the tongue C. Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad C. The client on Haldol has pill rolling tremors and muscle rigidity. Rape is an example of which type of crisis: A. You are afraid of being harmed. She is brought to the hospital by her mother. dystonia Answer: (B) Pseudoparkinsonism Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by masklike facies. Tardive dyskinesia is manifested by lip smacking. akinesia D. The client is manifesting: A. tardive dyskinesia B. Akinesia is characterized by feeling of weakness and muscle fatigue D. Splitting B. You are afraid of being harmed. Developmental D. “The NBI is not out to catch you.” C. They are transitional or developmental periods in life . unnecessary exploration of the false 89. pill rolling tremors. Situational crisis is from an external source that upset ones psychological equilibrium C and D. “I don’t believe that. Are the same. are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged D. The client is very hostile toward one of the staff for no apparent reason. Resistance Answer: (B) Transference Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. muscle rigidity A.” D. Countertransference D. “ What made you think of that. Adventitious C.” B. It is not part of everyday life. Transference C. Situation: An 18 year old female was sexually attacked while on her way home from work.” This presents reality and acknowledges the clients feeling A and B. Pseudoparkinsonism C.A. Dystonia is manifested by torticollis and rolling back of the eyes 90. Resistance is the client’s refusal to submit himself to the care of the nurse 91.

B and C are interventions or strategies to attain the goal 95. Guilt feeling is common among rape victims. Maintain a non-judgmental approach. A. C. Assure privacy.The client is anxious. Generalized Anxiety Disorder D. Support her adaptive coping skills D. She is likely suffering from: A. B. depression and work or social impairments. Five months after the incident the client complains of difficulty to concentrate. Accompany the client in the examination room. The nurse acts a a counselor B. D. Answer: (B) Touch the client to show acceptance and empathy The client finds touch intrusive and therefore should be avoided. D. The nurse acts as a technician D. They should not be blamed. Adjustment disorder B. Assist the client to express her feelings B. Somatoform disorders are anxiety related disorders characterized by presence of physical symptoms without demonstrable organic basis C. Post traumatic disorder Answer: (D) Post traumatic disorder Post traumatic stress disorder is characterized by flashback. Generalized anxiety disorder is characterized by chronic. B. This lasts for more that one month A. poor appetite. She assesses the client for injuries. irritability. Explains to the client that her reactions are normal Answer: (C) She postpones the physical assessment until the client is calm The nurse acts as a patient advocate as she protects the client from psychological harm A. The nurse acts as a patient advocate when she does one of the following: A. Crisis intervention carried out to the client has this primary goal: A. This occurs within 3 months after the event B. Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety. Privacy is one of the rights of a victim of rape. Touch the client to show acceptance and empathy C. During the initial care of rape victims the following are to be considered EXCEPT: A. Help her return to her pre-rape level of function Answer: (D) Help her return to her pre-rape level of function The goal of crisis intervention to help the client return to her level of function prior to the crisis. 93. She encourages the client to express her feeling regarding her experience. She postpones the physical assessment until the client is calm D. difficulty falling asleep and concentrating following an extremely traumatic event. excessive anxiety for at least 6 months . A. Accompanying the client in a quiet room ensures safety and offers emotional support. This exemplifies the role of a teacher 94. Help her identify her resources C. inability to sleep and guilt. Somatoform Disorder C.92. C.

with rapid speech headache and inability to focus with what the doctor was saying. feeling of being overwhelmed and disorganization 97. Explain in detail the plan of care developed D. Ask the client to identify the cause of her anxiety. The client will not be able to identify the cause of anxiety C and D. masked depression Answer: (B) a subjectively perceived threat Anxiety is caused by a subjectively perceived threat A. The nurse assesses the level of anxiety as: A. Antimanic 100. Lithium Answer: (B) Valium Antianxiety A. The client has narrowed perceptual field.96. Mild B. A depressed client internalizes hostility D. increased rate of speech and difficulty in concentrating are noted in moderate anxiety. hostility turned to the self D. A Mild anxiety is manifested by slight muscle tension. Fear is caused by an objective threat C. incoherence. It would be most helpful for the nurse to deal with a client with severe anxiety by: A. B. L engthy explanations cannot be followed by the client. Anxiety is caused by: A. an objective threat B. ability to concentrate and capable of problem solving. slight fidgeting. C. Panic Answer: (C) Severe The client’s manifestations indicate severe anxiety. Mania is due to masked depression 98. periodic slow pacing. Urge the client to focus on what the nurse is saying Answer: (A) Give specific instructions using speak in concise statements. B. D. The client has difficulty concentrating and will not be able to focus. Which of the following is included in the health teachings among clients . Prozac B. Which of the following medications will likely be ordered for the client?” A. Risperdal D. 99. Severe D. Moderate C. Situation: A 29 year old client newly diagnosed with breast cancer is pacing. Antidepressant C. Antipsychotic D. Give specific instructions using speak in concise statements. Valium C. alertness. Panic level of anxiety is characterized immobilization. a subjectively perceived threat C. Moderate muscle tension. increased vital signs. B.

2008 ) ONLINE READINESS TEST: NLE REVIEW • • • • • Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008) Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) Leadership. It can intensify the CNS depressant effects. . Bioethics and Research : Nursing Online Readiness Test (Nursing Licensure Examination November 2008) Community Health Nursing: Nursing Online Readiness Test: (NLE Nov. D. D The dose of Valium should not be doubled if the previous dose was not taken.Related Nursing Articles ONLINE READINESS TEST: NLE REVIEW • • • • • Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008) Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) Leadership. A. 2008 ) .org . Avoid foods rich in tyramine. Antianxiety medications cause G. It is safe to stop it anytime after long term use. the medication should be gradually withdrawn to prevent the occurrence of convulsion.receiving Valium?: A. Valium causes dependency. upset so it should be taken after meals. Bioethics and Research : Nursing Online Readiness Test (Nursing Licensure Examination November 2008) Community Health Nursing: Nursing Online Readiness Test: (NLE Nov. Article copyright NurseReview. Double up the dose if the client forgets her medication. This is specific for antidepressant MAOI. In which case. C. Management. Taking tyramine rich food can cause hypertensive crisis.I. No part of an article may be reproduced without the prior permission. Management. Answer: (B) Take the medication after meals. C. All rights reserved.#1 source of information to update nurses all over the world. B. Take the medication after meals.

Bioethics and Research : Nursing Online Readiness Test (Nursing Licensure Examination November 2008) Community Health Nursing: Nursing Online Readiness Test: (NLE Nov. Bioethics and Research : Nursing Online Readiness Test (Nursing Licensure Examination November 2008) Community Health Nursing: Nursing Online Readiness Test: (NLE Nov. Management. 2008 ) charted by Online NLE Reviewer 2 comments Labels: NURSING ONLINE READINESS TEST: NLE REVIEW Bookmark this post:  Job Search for Nurses RN/LVN .ONLINE READINESS TEST: NLE REVIEW • • • • • Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008) Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) Leadership. Management. 2008 ) ONLINE READINESS TEST: NLE REVIEW • • • • • Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008) Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) Leadership. Management. 2008 ) ONLINE READINESS TEST: NLE REVIEW • • • • • Psychiatric Nursing: Nursing Online Readiness Test (PRC NLE Review November 2008) Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) Leadership. Bioethics and Research : Nursing Online Readiness Test (Nursing Licensure Examination November 2008) Community Health Nursing: Nursing Online Readiness Test: (NLE Nov.

 Forum. experience reduced sensory perception D. Hacks. Thank you so much. 2.breathing and coughing exercises. ETC. Thursday. WRONG ANSWERS. MEDICAL SURGICAL NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB.” C. 2008 Medical Surgical Nursing: Nursing Online Readiness Test (NLE November 2008 Review) If you're new here.” D. Tricks. The nurse’s best response would be: A.” Applying pressure against the incision with a pillow will help lessen the intraabdominal pressure created by coughing which causes tension on the incision that leads to pain. Mario complains of mild incisional pain while performing deep. “With a pillow.” B. INCONSISTENCIES. . NurseReview. Enjoy! If you like this post.. “This is a normal reaction after surgery. apply pressure against the incision. apply pressure against the incision. alterations in neural pathways and diminished processing of sensory data. you may want to subscribe to my RSS feed. USE THIS AT YOUR DESGRESSION 1. and more.NurseReview.” Answer: (C) “With a pillow. “I will give you the pain medication the physician ordered.Org . “Pain will become less each day.Org IS NOT RESPONSIBLE FOR ANY TYPOS. Following surgery. WRONG RATIONALE. The nurse needs to carefully assess the complaint of pain of the elderly because older people A. November 20. are expected to experience chronic pain B.Tips. The response to pain in the elderly maybe lessened because of reduced acuity of touch. Digg It! Click on the Digg button.Forum for Nurses!  Book Of Tips . One advantage of subscribing to RSS feeds is that you don't have to constantly re-visit this site to check for updates within specific sections you might be interested in because your browser or Feed reader will do this for you automatically on a regular basis plus you can even get email notification. have a decreased pain threshold C. have altered mental function Answer: (C) experience reduced sensory perception Degenerative changes occur in the elderly.

you appear anxious to me. Pablo. What is needed is promotion for adequate oxygenation and perfusion.3. The patient needs a higher dose of this drug C. D. "Good evening. Pablo. Administer the prescribed antiemetic. you must be so worried. Checking on the patency of the NGT for any . you'll wear out the hospital floors and yourself at this rate. How are you feeling about tomorrow's surgery?" Answer: (D) "Mr. C. Administer Demerol 50mg IM q4h Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol. D. Which action would the nurse take? A. is scheduled for a cystectomy with the creation of an ileal conduit in the morning. Call the physician immediately. which is a narcotic analgesic. Insertion of the NGT helps relieve the problem. which of the following orders would the nurse question? A. "Mr. you appear anxious to me. He is wringing his hands and pacing the floor when the nurse enters his room. This is normal side-effect of AtSO4 D. She continues to complain of nausea. 4. a pulse of 140. "Mr. After surgery. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher. B. Suspecting shock. today?" B. Pablo. 5. I'll leave you alone with your thoughts. Monitor urine output every hour. All the other interventions can be expected to be done by the nurse." D. B. diagnosed with Bladder Cancer. The patient is anxious about upcoming surgery Answer: (C) This is normal side-effect of AtSO4 Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate. B. “Mr. How are you feeling about tomorrow's surgery?" The client is showing signs of anxiety reaction to a stressful event. Mr. Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. than before the medication was administered. Pablo. Mr. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg. 6. and respirations of 32. Answer: (C) Check the patency of the nasogastric tube for any obstruction. Pablo. Put the client in modified Trendelenberg's position. Pablo. Nausea is one of the common complaints of a patient after receiving general anesthesia. The patient is having an allergic reaction to the drug. The nurse’s best A. What is the best approach? A. can depress respiratory and cardiac function and thus not given to a patient in shock. Check the patency of the nasogastric tube for any obstruction. C. Wasn't it a pleasant day. Administer oxygen at 100%. Change the patient’s position. C.

At 10 am and at 11 am. B. Complete A. the patient needs to be supported and handled gently. his vital signs are stable. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring. Complications can occur during this period as a result of the surgery or the anesthesia or both. What nursing action is most appropriate? A. A depressed fontanel C. 9.obstruction will help the nurse determine the cause of the problem and institute the necessary intervention. Mr. Answer: (B) Take his vital signs again in 15 minutes. 7. respirations are 20. blood pressure is 116/74. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client. and respirations are 24. Pain medication provides little relief and he refuses to move. care quickly as possible when necessary Answer: (C) Handle him gently when assisting with required care Patients with cancer and bone metastasis experience severe pain especially when moving. “I exercise every other day. A client returns from the recovery room at 9AM alert and oriented. Perez is in continuous pain from cancer that has metastasized to the bone. An elevated temperature Answer: (C) Bleeding from ears The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function. however. his pulse rate is 94. The nurse should plan to: A. 8. His pulse is 82. statements by the client to the nurse indicates a risk factor for CAD? A. Take his vital signs again in an hour. Notify his physician. Reassure him that the nurses will not hurt him B. At noon. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation 10. with an IV infusing. the nurse would be most concerned if the assessment revealed: A. Reactive pupils B. blood pressure is 120/80. D. During nursing care. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Handle him gently when assisting with required care D. C. Let him perform his own activities of daily living C. and all are within normal range.M. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. Which of the ff. fractures and bleeding. Place the patient in shock position. increased intracranial pressures.” . Bleeding from ears D. Take his vital signs again in 15 minutes.

Use of stool softeners. Lifting heavy objects Answer: (A) Use of stool softeners. liver and renal problems D. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Exercise and maintaining normal serum cholesterol levels help in its prevention. 12. “When your chest pain begins.” D.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. It has positive inotropic and negative chronotropic effects B. “My father died of Myasthenia Gravis. Do not give the drug if the apical rate is less than 60 beats per minute. Which of the following activities will not stimulate Valsalva's maneuver? A. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? A. A patient with angina pectoris is being discharged home with nitroglycerine tablets. 13. “My cholesterol is 180. 14. OD.B.” C. The nurse is teaching the patient regarding his permanent artificial pacemaker. Answer: (B) The positive inotropic effect will decrease urine output Inotropic effect of drugs on the heart causes increase force of its contraction. Mr. This will prevent trauma to the area of the pacemaker generator. have regular follow up care D. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver. take the pulse rate once a day. D. Enema administration C. The positive inotropic effect will decrease urine output C. Which of the following instructions does the nurse include in the teaching? A.25 mg. and place one tablet under your . lie down. Which is poor knowledge regarding this drug? A. Valsalva maneuver can result in bradycardia. Toxixity can occur more easily in the presence of hypokalemia. “I smoke 1 1/2 packs of cigarettes per day. may be allowed to use electrical appliances C. Gagging while toothbrushing. in the morning upon awakening B. 11.” Answer: (D) “I smoke 1 1/2 packs of cigarettes per day. may engage in contact sports Answer: (D) may engage in contact sports The client should be advised by the nurse to avoid contact sports. B. Braga was ordered Digoxin 0. This increases cardiac output that improves renal perfusion resulting in an improved urine output.

then go lie down. Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. The nurse is conducting an education session for a group of smokers in a . Heparin is an anticoagulant. Elevate the client's legs 90 degrees. Answer: (C) Instruct the client about the need for bed rest. D. It does not dissolve a clot. 15. Go to the hospital if the pain is unrelieved. If the pain is not relieved in 15 minutes. Which action by this team member is most appropriate? A. Apply a heating pad to the involved site. C. “Continue your activity. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis.” B. If the pain continues. 18. B. “Place one tablet under your tongue. D. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food? A. Whole milk B. A client receiving heparin sodium asks the nurse how the drug works. Provide active range-of-motion exercises to both legs at least twice every shift. 17. begin taking the nitro tablets one every 5 minutes for 15 minutes.tongue. B. bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. Go to the hospital if the pain is unrelieved. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. take another tablet in 5 minutes. If the chest pain is unrelieved. and if the pain does not go away in 10 minutes. Instruct the client about the need for bed rest.” C. It prevents the conversion of prothrombin to thrombin. go to the hospital. In a client with thrombophlebitis. there is a possibility of acute coronary occlusion that requires immediate medical attention. It prevents conversion of factors that are needed in the formation of clots. It inactivates thrombin that forms and dissolves existing thrombi. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply.” D. It interferes with vitamin K absorption. Eggs Answer: (B) Canned sardines Canned foods are generally rich in sodium content as salt is used as the main preservative. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. C. Which of the following points would the nurse include in the explanation to the client? A. after three tablets. of sodium per day. A client with chronic heart failure has been placed on a diet restricted to 2000mg. 16. “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. It dissolves existing thrombi. Canned sardines C. Plain nuts D.

The irritation causes the cough which initially maybe dry. Hyperoxygenate the client before and after suctioning Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. The hypoxic state of the client then becomes the stimulus for breathing. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. B. Cough or change in a chronic cough Answer: (D) Cough or change in a chronic cough Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. When suctioning mucus from a client's lungs. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. Wheezing sound on inspiration D. A . Suctioning sucks not only the secretions but also the gases found in the airways. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. 21. C. Cause less irritation to the gastrointestinal tract B. When informing the client of this decision. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. the nurse knows that the purpose of this choice of treatment is to A. Which is the most relevant knowledge about oxygen administration to a client with COPD? A. Dr. Which finding would the nurse state as a common symptom of lung cancer? : A. Foamy. 19. Use sterile technique with a two-gloved approach C. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive. persistent and unproductive. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. obstruction of the airways occurs and the cough may become productive due to infection. Blood gases are monitored using a pulse oximeter. Lubricate the catheter tip with sterile saline before insertion. Destroy resistant organisms and promote proper blood levels of the drugs C. Gain a more rapid systemic effect D. 20. As the tumor enlarges. B. which nursing action would be least appropriate? A. blood-tinged sputum C. Suction until the client indicates to stop or no longer than 20 second D. Delay resistance and increase the tuberculostatic effect Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons.“stop smoking” class. Oxygen is administered best using a non-rebreathing mask D. Dyspnea on exertion B.

there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. Slowly breath out through the mouth with pursed lips after inhaling the drug. In the postanesthesia care unit Mario is placed in Fowler's position on either his right side or on his back to A. Only ice chips and cold liquids will be allowed initially. What is the nurse’s best initial action? . Increase venous return Answer: (B) Facilitate ventilation of the left lung. Chest tubes are inserted. 23. Hold his breath for about 10 seconds before exhaling D. The client's nasal cannula oxygen is running at a rate of 6 L per minute. Answer: (A) Food and fluids will be withheld for at least 2 hours. When teaching the client what to expect afterward. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. Equalize pressure in the pleural space. the nurse's highest priority of information would be A. Facilitate ventilation of the left lung. A client is scheduled for a bronchoscopy.prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. 22. D. The nurse enters the room of a client with chronic obstructive pulmonary disease. A client with COPD is being prepared for discharge. Using drugs in combination can delay the drug resistance. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. Warm saline gargles will be done q 2h. B. 24. this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness. B. C. Breath in and out as fully as possible before placing the mouthpiece inside the mouth. Coughing and deep-breathing exercises will be done q2h. Since only a partial pneumonectomy is done. Mario undergoes a left thoracotomy and a partial pneumonectomy. Prior to bronchoscopy. 25. Food and fluids will be withheld for at least 2 hours. and the respirations are 9 per minute and shallow. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT A. If the client breathes out through the mouth with pursed lips. The gag reflex usually returns after two hours. D. C. the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. the skin color is pink. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. B. Reduce incisional pain. and one-bottle water-seal drainage is instituted in the operating room. Inhale slowly through the mouth as the canister is pressed down C.

The hypoxic drive is his chief stimulus for breathing. this makes him prone to fluid volume excess. Decreased tissue perfusion. Take heart rate and blood pressure. posterior neck fat pad and thin extremities Answer: (D) posterior neck fat pad and thin extremities “Buffalo hump” is the accumulation of fat pads over the upper back and neck. Risk for infection Answer: (C) Impaired gas exchange. 28. Pneumonia. D. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug.” C. “This medicine will protect me from getting any colds or infection. which is an infection. A client. Position the client in a Fowler's position. B. 26. “I must take this medicine exactly as my doctor ordered it.A. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity? A. Because the patient would require adequate hydration. pendulous abdomen and large hips C. Answer: (C) Lower the oxygen rate. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Call the physician. abdominal striae and ankle enlargement D. causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. The client with COPD is suffering from chronic CO2 retention.” Answer: (B) “I must take this medicine exactly as my doctor ordered it. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy? A. Which is the most appropriate nursing diagnosis for this patient? A. I shouldn’t skip doses. 27.” D. All these are noted in a client with Cushing’s syndrome. Lower the oxygen rate. I shouldn’t skip doses.” The possible side effects of steroid administration are hypokalemia. D. Impaired gas exchange. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis 29. complains of . There is truncal obesity but the extremities are thin. Fluid volume deficit B. who is suspected of having Pheochromocytoma. C. large thighs and upper arms B. C. increase tendency to infection and poor wound healing. Fat may also accumulate on the face. “My incision will heal much faster because of this drug.” B. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face.

who is newly diagnosed with Graves disease. 32. Blood glucose Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.” D. the nurse should include in her care: A. Checking the back and sides of the operative dressing B. tremors.” C. Pupil reaction B. During the first 24 hours after thyroid surgery. starts to tremble and complains of dizziness. Hand grips C. The nurse is attending a bridal shower for a friend when another guest.” Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease. “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease. When this occurs in a conscious client. he should be given immediately carbohydrates in the form of fruit juice. Encourage the guest to eat some baked macaroni B. Encouraging the client to ventilate her feelings about the surgery D. who happens to be a diabetic. Call the guest’s personal physician C. asks the nurse. “The medication limit synthesis of the thyroid hormones. if unconscious. Advising the client that she can resume her normal activities immediately Answer: (A) Checking the back and sides of the operative dressing Following surgery of the thyroid gland.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease. bleeding is a potential complication. Supporting the head during mild range of motion exercise C. “The medication will block the cardiovascular symptoms of Grave’s disease. The next best action for the nurse to take is to: A. palpitation and headache. Give the guest a glass of orange juice Answer: (D) Give the guest a glass of orange juice In diabetic patients. glucagons or dextrose per IV. “The medication will increase the synthesis of thyroid hormones.sweating. 30. An adult. hard candy. 31. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry . weakness. the best response would be: A. honey or.” B. pallor diaphoresis and tachycardia. the nurse should watch out for signs of hypoglycemia manifested by dizziness. Blood pressure D. Which assessment is essential for the nurse to make first? A. Offer the guest a cup of coffee D. “The medication will limit thyroid hormone secretion.

Dry skin and fatigue C. Keep legs elevated on 2 pillows while sleeping D. Maintain NGT to intermittent suction B. has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client. causing erratic insulin absorption rates from these Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injection sites can never be reused Answer: (C) Lipodystrophic areas can result. Poor rotation technique can cause superficial hemorrhaging C. is characterized by hypometabolism that manifests itself with weight gain. 33. Keep the insulin not in use in the refrigerator Answer: (C) Keep legs elevated on 2 pillows while sleeping The client with DM has decreased peripheral circulation caused by microangiopathy. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions. Keeping the legs elevated during sleep will further cause circulatory impairment. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin? A. Lipodystrophy can result and is extremely painful B. Inspect feet and legs daily for any changes C. Assess for pain and medicate as ordered D. . 36. 35. Progressive weight gain D. Change position hourly to increase circulation B. Insomnia and excitability Answer: (C) Progressive weight gain Hypothyroidism. Intolerance to heat B. Giving fluids and food at this time can lead to aspiration. a decrease in thyroid hormone production. after gastroscopy. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops: A. 34. Lipodystrophic areas can result. On discharge. the nurse teaches the patient to observe for signs of surgically induced hypothyroidism.and clear of drainage. causing erratic insulin absorption rates from these D. Included in the plan of care for the immediate post-gastroscopy period will be: A. Which of the following would be inappropriate to include in a diabetic teaching plan? A. Assess gag reflex prior to administration of fluids C.

37. dull. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention. Sharp pain in the epigastric area that radiates to the right shoulder D. 38. Notify the MD of your findings C. Included in the plan of care for the immediate post-gastroscopy period will be: A. hungerlike pain in the epigastric area that is relieved by food intake Duodenal ulcer is related to an increase in the secretion of HCl. Maintain NGT to intermittent suction B. dull. has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Take only sips of H2O between bites of solid food C. the client developed dumping syndrome. Reposition the NGT by advancing it gently NSS B. Measure abdominal girth every 4 hours Answer: (B) Assess gag reflex prior to administration of fluids The client. The client underwent Billroth surgery for gastric ulcer. The most appropriate nursing action is to: A. Which of the following should the nurse exclude in the plan of care? A. Discontinue the low-intermittent suction Answer: (B) Notify the MD of your findings The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. Irrigate the NGT with 50 cc of sterile D.36. aching. Eat small meals every 2-3 hours D. 39. Assess for pain and medicate as ordered D. After Billroth II Surgery. Assess gag reflex prior to administration of fluids C. Giving fluids and food at this time can lead to aspiration. Sit upright for at least 30 minutes after meals B. after gastroscopy. the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. Gnawing. Which description of pain would be most characteristic of a duodenal ulcer? A. A sensation of painful pressure in the midsternal area Answer: (A) Gnawing. This can be buffered by food intake thus the relief of the pain that is brought about by food intake. RUQ pain that increases after meal C. aching. causing distention of the duodenum or jejunum produced by a bolus of . Post-operatively. Reduce the amount of simple carbohydrate in the diet Answer: (A) Sit upright for at least 30 minutes after meals The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying. hungerlike pain in the epigastric area that is relieved by food intake B.

Empty bladder before procedure C. Giving antibiotics will control the infection and Ranitidine. What instructions should the client be given before undergoing a paracentesis? A. Empty bowel before procedure Answer: (B) Empty bladder before procedure Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. will reduce acid secretion that can lead to ulcer.” B. NSAIDS C. Sitting up after meals will promote the dumping syndrome. 42. NPO 12 hours before procedure B. Treatment will include Ranitidine and Antibiotics B. which is a histamine-2 blocker. What statement by the nurse would best explain the purpose of the diet? A. Which of the following statements indicate an understanding of this data? A. “Most people have too much protein in their diets. Morphine B. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. 40. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. 41. This result indicates gastric cancer caused by the organism D.” The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Surgical treatment is necessary Answer: (A) Treatment will include Ranitidine and Antibiotics One of the causes of peptic ulcer is H. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease.food.” Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system. The amount of this diet is better for liver healing. 43. No treatment is necessary at this time C. Pylori infection. To delay the emptying. “Because of portal hyperemesis. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure. Which of the drug of choice for pain controls the patient with acute pancreatitis? A. the client has to lie down after meals.” C. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system. Meperidine .” D. “The liver heals better with a high carbohydrates diet rather than protein. A protein-restricted diet will therefore decrease ammonia production. Strict bed rest following procedure D. the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.

D. Codeine Answer: (C) Meperidine Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic. 44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is: A. encouraging the client to take adequate deep breaths by mouth B. encouraging the client to cough and deep breathe C. changing the dressing at least BID D. irrigate the T-tube frequently Answer: (B) encouraging the client to cough and deep breathe Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications. 45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to: A. Deflate the esophageal balloon B. Monitor VS C. Encourage him to take deep breaths D. Notify the MD Answer: (A) Deflate the esophageal balloon When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction 46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease? A. Chrons disease B. Ulcerative colitis C. Diverticulitis D. Peritonitis Answer: (B) Ulcerative colitis Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem. 47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:

A. Give laxative the night before and a cleansing enema in the morning before the test B. Render an oil retention enema and give laxative the night before C. Instruct the client to swallow 6 radiopaque tablets the evening before the study D. Place the client on CBR a day before the study Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema. 48. The client has a good understanding of the means to reduce the chances of colon cancer when he states: A. “I will exercise daily.” B. “I will include more red meat in my diet.” C. “I will have an annual chest x-ray.” D. “I will include more fresh fruits and vegetables in my diet.” Answer: (D) “I will include more fresh fruits and vegetables in my diet.” Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer. 49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to A. Cover the wound with sterile, moist saline dressing B. Approximate the wound edges with tapes C. Irrigate the wound with sterile saline D. Hold the abdominal contents in place with a sterile gloved hand Answer: (A) Cover the wound with sterile, moist saline dressing Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process. 50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to A. Strain all urine. B. Ambulate. C. Remain on bed rest. D. Ask for medications to relax him.

Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination. 51. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance? A. Hyponatremia B. Hyperkalemia C. Hyperphosphatemia D. Hypercalcemia Answer: (A) Hyponatremia The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting 52. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure? A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained. 53. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt? A. Heparinize it daily. B. Avoid taking blood pressure measurements or blood samples from the affected arm. C. Change the Silastic tube daily. D. Instruct the client not to use the affected arm. Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.

Explain the purpose and function of a two-way irrigation system. right lower quadrant D. the nurse should be looking for tenderness on palpation at McBurney’s point. telling him to avoid heavy lifting for 4 to 6 weeks B. right upper quadrant Answer: (C) right lower quadrant To be exact. He will be pain free.54. Telling the pain that he will be pain free is giving him false reassurance. left upper quadrant C. anterior chest. A 30-year-old homemaker fell asleep while smoking a cigarette. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. He is scheduled for a transurethral resection of the prostate (TURP). D. we allot the . recommending him to drink eight glasses of water daily Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. B. 18% B. instructing him to have a soft bland diet for two weeks C. which is the best estimate of total body-surface area burned? A. 22% C. 57. the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant. She sustained severe burns of the face. Expect bloody urine. C. TURP is the most common operation for BPH. Mr.neck. telling him to resume his previous daily activities without limitations D. Discharge teaching should include A. Valdez has undergone surgical repair of his inguinal hernia. which will clear as healing takes place. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case. Using the rule of nines. It would be inappropriate to include which of the following points in the preoperative teaching? A. On physical examination. 56. left lower quadrant B. and both arms and hands. Answer: (D) He will be pain free. which is located in the A. 31% D. Surgical interventions involve an experience of pain for the client which can come in varying degrees. 55. Romeo Diaz. is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). 40% Answer: (C) 31% Using the Rule of Nine in the estimation of total body surface burned. age 78.

61. Helping the client to rest in the position of maximal comfort Answer: (D) Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. and dyspnea D. Excessive renal perfusion with diuresis C. which nursing measure would be least effective to help prevent contractures? A. 18% .each lower extremity and 1% . Debriding and covering the wounds B.entire back. noisy and difficult breathing. If a burn is located on the upper torso. which item would be a primary concern? A. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness. Changing the location of the bed or the TV set. evaluation of the peripheral IV site B. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output. If a client has severe bums on the upper torso. especially resulting from thermal injury related to fires can lead to inhalation burns. 60. Administering antibiotics C. 59. Avoiding the use of a pillow for sleep. or placing the head in a position of hyperextension D.each upper extremity. An increase in the total volume of intracranial plasma B. stridor.head. Fluid shift from interstitial space D. 18%. Encouraging the client to chew gum and blow up balloons C. An adult is receiving Total Parenteral Nutrition (TPN). and dyspnea Burns located in the upper torso. 9% . Frequently observing for hoarseness.following: 9% .front chest and abdomen. Maintaining a patent airway is a primary concern. confirmation that the tube is in the stomach C. Contractures are among the most serious long-term complications of severe burns. or both.perineum. 58. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. 18% . Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by: A. Fluid shift from intravascular space to the interstitial space Answer: (D) Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. But this approach can lead to contracture deformities and other complications. stridor. Which of the following assessment is essential? A. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. Establishing a patent IV line for fluid replacement Answer: (C) Frequently observing for hoarseness. daily B. assess the bowel sound .

Which drug would be least effective in lowering a client's serum potassium level? A. All the other medications mentioned help treat hyperkalemia and its effects.9% NaCl C. Calcium glucomite D. electrolytes.45% NaCl has a lower tonicity that the blood. D5NSS Answer: (A) 0. vitamins. The SNS stimulation constricts renal arterioles that increases release of aldosterone. and D5NSS is hypertonic with a higher tonicity thab the blood. 40 years old. Aluminum hydroxide Answer: (D) Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. Because of its composition. Nursing care during the preoperative period should consist of . hypertension B. tachypnea Answer: (A) hypertension In hypovolemia. The admixture is made up of proteins.45% NaCl B. Looking at the following labeled solutions. 0. single. trace minerals and sterile water based on individual client needs. 63. Maria Sison. fluid and electrolyte monitoring Answer: (D) fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. She was scheduled for radical mastectomy. Polystyrene sulfonate (Kayexalate) C. A nurse is directed to administer a hypotonic intravenous solution. It is intended to improve the clients nutritional status. one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. fats. A patient is hemorrhaging from multiple trauma sites. tachycardia D. Glucose and insulin B.D. 0. she should choose A. blood glucose and weight. carbohydrates. 64. decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria. 65. 62. was admitted to the hospital with a diagnosis of Breast Cancer. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT A. D5W D. it is important to monitor the clients fluid intake and output including electrolytes. 0. oliguria C.45% NaCl Hypotonic solutions like 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood.

assessing Maria's expectations and doubts C. assuring Maria that she will be cured of cancer B. The initial stage in the grieving process is denial. it has been proven as a complete cure for cancer D. statements about chemotherapy is true? A. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery. Answer: (B) recognize that Kathy is experiencing denial. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed. The nurse should A. a normal stage of the grieving process C. 67. The nurse should show acceptance of the patient’s feelings and encourage verbalization. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. D. She believes that her breast is intact under the dressing. recognize that Kathy is experiencing denial. 68. thus the effect of bone marrow depression. Which of the ff. Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor . But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow. keeping Maria's visitors to a minimum so she can have time for herself Answer: (B) assessing Maria's expectations and doubts Assessing the client’s expectations and doubts will help lessen her fears and anxieties. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves. a normal stage of the grieving process A person grieves to a loss of a significant object. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics? A. Endoscopy provides direct view of a body cavity to detect abnormality. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer B. followed by bargaining. it is a local treatment affecting only tumor cells B. then anger. CT scanning uses magnetic fields and radio frequencies to provide crosssectional view of tumor D. 66. depression and last acceptance. C. Maria refuses to acknowledge that her breast was removed. maintaining a cheerful and optimistic environment D. call the MD to change the dressing so Kathy can see the incision B. it affects both normal and tumor cells C.A. it is often used as a palliative measure. Answer: (B) it affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells.

restricting movement of the affected arm D. 72. The inability of the kidneys to excrete the drug metabolites B. Toxic effect of the antibiotic that are given concurrently D.” B.” Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.” C. This can be prevented by A. including potassium and purines. because the force might make me expel the application. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling. High uric acid levels may develop in clients who are receiving chemotherapy. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix? A. This is caused by: A. Which of the following interventions would be included in the care of plan in a client with cervical implant? . “I know that my primary nurse has to wear one of those badges like the people in the x-ray department. They can precipitate in the kidneys and block the tubules causing acute renal failure. is caused by the rapid destruction of large number of tumor cells. ensuring patency of wound drainage tube B.” D. MRI uses magnetic fields and radio frequencies to detect tumors. “My 7 year old twins should not come to visit me while I’m receiving treatment. Rapid cell catabolism C. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. Intracellular contents are released. into the bloodstream faster than the body can eliminate them. “I will try not to cough. . 71. A post-operative complication of mastectomy is lymphedema. placing the arm on the affected side in a dependent position C. The altered blood ph from the acid medium of the drugs Answer: (B) Rapid cell catabolism One of the oncologic emergencies.” Children have cells that are normally actively dividing in the process of growth. 69.CT scan uses narrow beam x-ray to provide cross-sectional view. Answer: (D) frequently elevating the arm of the affected side above the level of the heart. frequently elevating the arm of the affected side above the level of the heart. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself. but they are not necessary for anyone else who comes in here. “I should get out of bed and walk around in my room. the tumor lysis syndrome. 70.

Hypovolemia. C. 75. Hypervolemia. Hypovolemia. hypokalemia. no fluctuation in serum sodium and potassium levels. When assessing the client. Rigid posture and altered perceptual focus D. Mobility and vaginal irrigations are not done. An adult has just been brought in by ambulance after a motor vehicle accident. D. B. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm 74. wide fluctuations in serum sodium and potassium levels. hyperkalemia. Place the affected arm in a dependent position.A. Decreased physiologic functioning C. A rapid pulse and increased RR B. the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation? A. Active range of motion exercises of the arms once a day. Avoid BP measurement and constricting clothing on the affected arm B. Unlimited visitors C. Discourage feeding. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy? A. The nurse assesses that the client has entered the second phase of acute renal failure. washing or combing with the affected arm D. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Vaginal irrigation every shift Answer: (C) Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Increased awareness and attention Answer: (A) A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. Low residue diet D. C. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for . Loss of fluids and electrolytes occur. wide fluctuations in serum sodium and potassium levels. Hypervolemia. and hypernatremia. Nursing actions throughout this phase include observation for signs and symptoms of A. Patient is also strictly isolated to protect other people from the radiation emissions 73. and hypernatremia. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. below the level of the heart Answer: (A) Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. Frequent ambulation B. Answer: (C) Hypovolemia.

which detects need for oxygenation.survival. Pericardial tamponade Answer: (D) Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. and no fluid or air is found. B. This leads to right atrial and venous congestion manifested by a CVP reading above normal. is a priority to help detect its progress and provide for prompt management before the occurrence of complications. but the client's vital signs do not improve. Spontaneous pneumothorax B. Ruptured diaphragm C. Checking on the VS especially the RR. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. assessing her VS especially her RR Answer: (D) assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. The best indicator of adequate fluid balance during this period is A. 79. 77. Change in level of consciousness. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance. and the initial reading is 20 cm H^O. D. A central venous pressure line is inserted. When she arrives in the RR she is still in shock. Elevated hematocrit levels. 78. putting several warm blankets on her C. Hemothorax D. . Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Ms. Intervention for a pt. monitoring her hourly urine output D. This causes a decrease in tissue perfusion to the different organs of the body. The most likely cause of these findings is which of the following? A. Blood and fluids is administered intravenously (IV). A thoracentesis is performed on a chest-injured client. C. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. placing her in a trendeleburg position B. Answer: (B) Urine output of 30 to 50 ml/hr. The nurse's priority should be A. Estimate of fluid loss through the burn eschar. Urine output of 30 to 50 ml/hr. who has swallowed a Muriatic Acid includes all of the following except . Normal renal perfusion should produce 1ml/kg of BW/min. 76. Hypovolemia is a decreased in circulatory volume.

forces air out of the lungs and creates an artificial cough that expels the aspirated material. . Measures are taken to immediately remove the toxin or reduce its absorption. together with the return of breathing. washing the esophagus with large volumes of water via gastric lavage Answer: (A) administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Induce emptying of the stomach D. The pressure from the thrusts lifts the diaphragm. administering an irritant that will stimulate vomiting B. Pupils equal and react to light C. This includes gastric lavage and the administration of activated charcoal to absorb the poison. hot compresses applied at 15-minute intervals C. For corrosive poison ingestion. 80. Skin warm and dry B. such as in muriatic acid where burn or perforation of the mucosa may occur. neutralizing the chemical D. local anesthetics and antibacterial drops for 24 – 36 hrs. 82. Chemical burn of the eye are treated with A. cleansing the conjunctiva with a small cotton-tipped applicator Answer: (C) Flushing of the lids. The Heimlich maneuver (abdominal thrust). conjunctiva and cornea with tap or preferably sterile water D. instillation of local anesthetic and antibiotic is done. is the primary goal of CPR. Force air out of the lungs B. copious irrigation with normal saline. for acute airway obstruction. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest? A.A. Vomiting is only indicated when non-corrosive poison is swallowed. Increase systemic circulation C. 81. aspirating secretions from the pharynx if respirations are affected C. Positive Babinski's reflex Answer: (C) Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which. Signs of effective tissue perfusion will be noted after. In the hospital. B. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. gastric emptying procedure is immediately instituted. Flushing of the lids. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Put pressure on the apex of the heart Answer: (A) Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Palpable carotid pulse D. attempts to: A.

” The nurse best response is: A. He is pronounced dead on arrival. decrease mucosal swelling C. 84. When performing chest compressions. answering their questions and listening to them will provide the needed support for them to move on and be of support to one another. Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. decrease bronchial secretions Answer: (C) relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. John. “You should be grateful you are not blind. When his parents arrive at the hospital. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death. This is normal. increase BP B. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration. is brought to the ER after a vehicular accident. 85. the nurse understands the correct hand placement is located over the A. The client states ‘My vision is blurred. “As one ages. upper half of the sternum B. This is given to: A. ask them to stay in the waiting area until she can spend time alone with them B. A nurse is performing CPR on an adult patient. speak to both parents together and encourage them to support each other and express their emotions freely C.83.” . the nurse should: A. and I don’t easily see clearly when I get into a dark room. lower third of the sternum Answer: (C) lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. visual changes are noted as part of degenerative changes. lower half of the sternum D. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. 86. relax the bronchial smooth muscle D. 16 years old. They go into a stage of denial and anger in their grieving. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. Assisting them with information they need to know. upper third of the sternum C. The nurse is performing an eye examination on an elderly client.” B.

This is normal. Which of the following activities is not encouraged in a patient after an eye surgery? A. 88. teach the client and family about activity restrictions. 90. for 24 to 48 hrs after the procedure. It is enough for the nurse to speak clearly and slowly. Use appropriate hand motions B. Converse in a quiet room with minimal distractions Answer: (C) Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Which is least important information about LP? A. “You maybe able to improve you vision if you move slowly. Force fluids before and after the procedure. 89. Answer: (D) Force fluids before and after the procedure. B. Inform the client that a warm.” D. LP involves the removal of some amount of spinal fluid. flushed feeling and a salty taste may be B. A client is to undergo lumbar puncture. Nursing care of the client includes the following EXCEPT A. visual changes are noted as part of degenerative changes. sexual intercourse Answer: (D) sexual intercourse To reduce increases in IOP.” Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. Speak clearly in a loud voice or shout to be heard D. . “You should rest your eyes frequently. Which of the following indicates poor practice in communicating with a hearing-impaired client? A.” Answer: (B) “As one ages. Check pulse. 87. unless contraindicated. It may be used to inject air. the client is instructed to increase fluid intake to 3L. straining to have a bowel movement C. To facilitate CSF production. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision. sneezing. coughing and blowing the nose B. Maintain pressure dressing over the site of puncture and check for C. color and temperature of the extremity distal to the site of D. Kept the extremity used as puncture site flexed to prevent bleeding. Specimens obtained should be labeled in their proper sequence. dye or drugs into the spinal canal. wearing tight shirt collars D. C. Sexual intercourse can cause a sudden rise in IOP.C. Keep hands and other objects away from your mouth when talking to the client C. Assess movements and sensation in the lower extremities after the D.

Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. 91. A client with head injury is confused. The platelets are attracted to the area causing thrombi formation. Aspirin is used in the acute management of a completed stroke. This is initially manifested by restlessness. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. contralateral hemiparesis and ipsilateral dilation of the pupils D. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively. Ice bag can be applied intermittently to the puncture site. What would be the MOST therapeutic nursing action when a client’s expressive aphasia is severe? A. Keep us a steady flow rank to minimize silence D. Communicate by means of questions that can be answered by the client shaking the head C. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. progression from restlessness to confusion and disorientation to lethargy Answer: (D) progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. Thrombolytics are most useful within three hours of an occlusive CVA D. Which is irrelevant in the pharmacologic management of a client with CVA? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Anticipate the client wishes so she will not need to talk B. Expressive or motor aphasia is a result of damage in the Broca’s area of the frontal lobe. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for? A. abnormal respiratory pattern B. drowsy and has unequal pupils.Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding. Which . Answer: (D) Aspirin is used in the acute management of a completed stroke. Answer: (D) Encourage the client to speak at every possible opportunity. 94. 93. Aspirin is a platelet deaggregator used in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding. Anticonvulsants are given to prevent seizures C. Encourage the client to speak at every possible opportunity. 92. rising systolic and widening pulse pressure C.

and inspect the stump daily. sensory perceptual alteration Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Measure the specific gravity of th e fluid C. Which measure would be excluded from the teaching plan? A. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation. High risk for injury related to muscle weakness C. The client has clear drainage from the nose and ears after a head injury. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis? A. Measure the ph of the fluid B. pillow on a foot-stool). 97. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. high risk for injury C. altered level of cognitive function B. Pain B. 95. Treat superficial abrasions and blisters promptly. C. Ineffective airway clearance related to muscle weakness Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. B. Ineffective coping related to illness D. altered cerebral tissue perfusion D. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. How can the nurse determine if the drainage is CSF? A. progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. D. A positive result with the drainage indicate CSF leakage.g.. Test for chlorides Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. This leads to sporadic. Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. Toughen the stump by pushing it against a progressively harder substance (e.of the following nursing diagnosis is most important at this time? A. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal . dry. 96. Test for glucose D. Wash.

Keep the knees slightly flexed while the client is lying in a semi-Fowler's position in bed. Apply hot compresses to the affected joints. It should be applied with the distal end with the tighter arms. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. Before log rolling. A client had a laminectomy and spinal fusion yesterday. C. Answer: (D) Place items so that it is necessary to bend or stretch to reach them. The nurse should see to it therefore that objects are within easy reach of the patient. When developing a plan of care. B. which action would have the highest priority? A. Answer: (B) Before log rolling. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones. She is retired and has had to give up her volunteer work because of her discomfort. C. The “shrinker” bandage is applied to prevent swelling of the stump. Which would be excluded from the clinical pathway for this client? A.end of the affected limb. Slide items across the floor rather than lift them. Place items so that it is necessary to bend or stretch to reach them. A client is admitted from the emergency department with severe-pain and edema in the right foot. remove the pillow from under the client's head and use no pillows between the client's legs. His diagnosis is gouty arthritis. Patients with osteoarthritis have decreased mobility caused by joint pain. Before log rolling. it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing. She was told her diagnosis was osteoarthritis about 5 years ago. D. B. Keep a pillow under the client's head as needed for comfort. 98. Decrease the calorie count of her daily diet. 99. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. Ensure an intake of at least 3000 ml of fluid per day. Take warm baths when arising. Which statement is to be excluded from your plan of care? A. Following a laminectomy and spinal fusion. remove the pillow from under the client's head and use no pillows between the client's legs. D. Stress the importance of maintaining good posture to prevent deformities. Her major complaint is pain in her joints. C. B. She is 5 feet 4 inches tall and weighs 180 pounds. 100. Administer salicylates to minimize the inflammatory reaction. . place a pillow under the client's head and a pillow between the client's legs. D. A 70-year-old female comes to the clinic for a routine checkup. Overreaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.

The nurse would know that this teaching was effective when Joy says that exercise will: A. The drop factor of the IV set is 10 gtt/ml. Joy. The nurse would incorporate which of the ff. Lower her metabolic rate C. Raise her heart rate Answer: (A) Increase her lean body mass . 102. So it is the nurse’s primary responsibility to protect the patient from infection. The piggyback is to infuse in 20 minutes. with a balance of foods from the basic four food groups. a new dietary program. Decrease her appetite D. the nurse should bear in mind that long-term weight loss best occurs when: A. Before answering her question. must be established and continued 104. the value of aerobic exercises in her weight reduction program. 35 gtt/min D.101. The day after her surgery Joy asks the nurse how she might lose weight. 30 gtt/min C. The nurse teaches Joy. providing emotional support to decrease fear B. Carbohydrates are regulated D. Fats are controlled in the diet B. an obese client. She has a fractured hip and is brought to the OR for surgery. Exercise is part of the program Answer: (B) Eating habits are altered For weight reduction to occur and be maintained. is admitted to the hospital after an automobile accident. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse should set the piggyback to flow at: A. encouraging discussion about lifestyle changes D. Increase her lean body mass B. 25 gtt/min B. 45 gtt/min Answer: (A) 25 gtt/min To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20) 103. as a priority in the plan of care? A. an obese 32 year old. Eating habits are altered C. identifying factors that decreased the immune function Answer: (B) protecting the client from infection Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. protecting the client from infection C. After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W.

Relieves pain and decreases level of anxiety C. Both feet placed wide apart C. He is diagnosed with a myocardial infarct. The palms of her hands D. Exercising the triceps. The palms and axillary regions B. 10 minims C. The nurse should administer: A. The most important activity to facilitate walking with crutches before ambulation begun is: A. Doing isometric exercises on the unaffected leg D. and elbow extensors These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation. who had surgery for a fractured hip. The vial on hand is labeled 1 ml/ 10 mg. and elbow extensors B.Increased exercise builds skeletal muscle mass and reduces excess fatty tissue. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. Sitting up at the edge of the bed to help strengthen back muscles C. Will help prevent erratic heart beats B. Morphine sulfate. Decreases anxiety D. 106. 8 inches tall and weighs 190 pounds. finger flexors. 8 minims B. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on: A. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. Her axillary regions Answer: (C) The palms of her hands The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus) 107. Dilates coronary blood vessels . Using the trapeze frequently for pull-ups to strengthen the biceps muscles Answer: (A) Exercising the triceps. 105. The physician orders 8 mg of Morphine Sulfate to be given IV. The nurse replies that it: A. 15 minims Answer: (C) 12 minims Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate 108. He is 5 feet. The physician orders non-weight bearing with crutches for Joy. Diazepam (Valium) and Lidocaine are prescribed. finger flexors. 12 minims D.

SGPT B. Myra is ordered laboratory tests after she is admitted to the hospital for angina. They are therefore most reliable in assisting with early diagnosis. frustrations and anger about his . has been complaining to the nurse about issues related to his hospital stay. AST Answer: (C) CK-MB The cardiac marker. Has unstable properties C. peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. 112. The nurse institutes safety precautions in the room because oxygen: A. CK-MB D. The cardiac markers elevate as a result of myocardial tissue damage. Is flammable Answer: (C) Supports combustion The nurse should know that Oxygen is necessary to produce fire. 109. thus precautionary measures are important regarding its use. 110. The best initial nursing response would be to: A. who had a myocardial infarction 2 days earlier. Flattened T waves Answer: (B) Elevated ST segments This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The isoenzyme test that is the most reliable early indicator of myocardial insult is: A. Allow him to release his feelings and then leave him alone to allow him to regain his composure B.Answer: (B) Relieves pain and decreases level of anxiety Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. Converts to an alternate form of matter B. especially the MB sub-unit which is cardio-specific. Disappearance of Q waves B. begin to rise in 3-6 hours. The other choices are not typical of MI. Elevated ST segments C. Supports combustion D. Jose. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. Refocus the conversation on his fears. LDH C. 111. Creatinine phosphokinase (CPK) isoenzyme levels. Absence of P wave D. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand. An early finding in the EKG of a client with an infarcted mycardium would be: A.

Store vitamin B12 B. Attempt to explain the purpose of different hospital routines Answer: (B) Refocus the conversation on his fears. A Schilling test is ordered for Ana. 114. 55 years old. C. Elevated blood pressure D. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to: A. Increased BP. Ana.condition C. Twenty four hours after admission for an Acute MI. is admitted to the hospital to rule out pernicious anemia. “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to: A. Suggest he discuss his feelings of vulnerability with his physician. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor. the nurse must reflect and analyze the feelings that are implied in the client’s question. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand. 115. The focus should be on collecting data to minister to the client’s psychosocial needs. Chest pain C. Digest vitamin B12 C. Avoid giving him direct information and help him explore his feelings D. Answer: (C) Avoid giving him direct information and help him explore his feelings To help the patient verbalize and explore his feelings. The nurse monitors him for other adaptations related to the pyrexia. chest pain and shortness of breath are not typically noted in fever. This need for oxygen increases the heart rate. Tell him that he certainly needs to be especially careful about his diet and lifestyle. Absorb vitamin B12 D. Produce vitamin B12 Answer: (C) Absorb vitamin B12 Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach . Explain how his being upset dangerously disturbs his need for rest D. frustrations and anger about his condition This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Increased pulse rate Answer: (D) Increased pulse rate Fever causes an increase in the body’s metabolism. which results in an increase in oxygen consumption and demand. Jose’s temperature is noted at 39. who is admitted to the hospital for chest pain. which is reflected in the increased pulse rate. asks the nurse. Shortness of breath B. including: A. B. 113. Jose.3 C.

2. Intellectualization . The nurse should administer: A.0 ml Answer: (D) 2. Mr.5 ml B.” The nurse recognizes that the client is using the defense mechanism known as: A.2 mg of Cyanocobalamin (Vitamin B12) IM. Sublimation C.due to a lack of intrinsic factor in the gastric juices. muscles. The physician orders 0. 1. radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine. For the rest of her life Answer: (D) For the rest of her life Since the intrinsic factor does not return to gastric secretions even with therapy. blood and bone marrow 118. Inject 2 ml. to give 0. IM injections once a month will maintain control D. Available is a vial of the drug labeled 1 ml= 100 mcg. 119. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver. Cruz accuses the nurse of being uncomfortable during a dressing change. Reaction Formation B.0 ml First convert milligrams to micrograms and then use ratio and proportion (0. When she feels fatigued B. a 45 year old artist. Weekly Z-track injections provide needed control Answer: (C) IM injections once a month will maintain control Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor. 0. 1. heart. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. During exacerbations of anemia C.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. IM injections are required for daily control C. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it: A. has recently had an abdominoperineal resection and colostomy.2 mg of Cyanocobalamin. because his “wound looks terrible. B12 injections will be required for the remainder of the client’s life. kidney. Ana is diagnosed to have Pernicious anemia. Arthur Cruz. the transport carrier component of gastric juices.5 ml D. Until her symptoms subside D. In the Schilling test. Oral tablets of Vitamin B12 will control her symptoms B. B12 will include: A. 117.0 ml C. 116.

a client with colostomy should be instructed to report to his physician : A. The procedure may take longer than half an hour. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. Stops the flow of fluid when he feels uncomfortable B. When observing an ostomate do a return demonstration of the colostomy irrigation. the nurse should plan to perform the procedure: A. Inability to complete the procedure in half an hour Answer: (B) Difficulty in inserting the irrigating tube Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Difficulty in inserting the irrigating tube C. Impotency due to the surgery and needs sexual counseling . 120. A difficult time accepting reality and is in a state of denial. B. 122. Before breakfast and morning care D. When doing colostomy irrigation at home. 121.D. Hangs the bag on a clothes hook on the bathroom door during fluid insertion D. Lubricates the tip of the catheter before inserting it into the stoma C. Abdominal cramps during fluid inflow B. 123. a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient. can assume that the client is experiencing: A. When the client would have normally had a bowel movement B. A reaction formation to his recent altered body image. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion The irrigation bag should be hung 12-18 inches above the level of the stoma. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The nurse on assessing this data. Projection Answer: (D) Projection Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition. C. After the client accepts he had a bowel movement C. Passage of flatus during expulsion of feces D. When preparing to teach a client with colostomy how to irrigate his colostomy. At least 2 hours before visitors arrive Answer: (A) When the client would have normally had a bowel movement Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit. the nurse notes that he needs more teaching if he: A.

Assess his response to the equipment D. Food low in fiber so that there is less stool B. Soft foods that are more easily digested and absorbed by the large intestines Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas There is no special diets for clients with colostomy. the assessment that assume the greatest priority are: A. 40 years old. It is feared his leg may have to be amputated. the client’s denial is supported 124. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat: A. a plane crash victim. Level of consciousness and pupil size B. Eddie. Only gas-forming foods that cause distention and discomfort should be avoided. Basic life functions must be maintained or reestablished 126. Respiratory rate and blood pressure D. He has suffered multiple crushing wounds of the chest. These are top priorities to trauma management. Eddie. When Eddie arrives in the emergency room. Facilitate his verbal communication B. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses Respiratory and cardiovascular functions are essential for oxygenation. abdomen and legs.D. Abdominal contusions and other wounds C. undergoes endotracheal intubation and positive pressure ventilation. Pain. Suicide thoughts and should be seen by psychiatrist Answer: (B) A difficult time accepting reality and is in a state of denial. Nothing is achieved if the equipment is working and the client is not responding . These clients can eat a regular diet. is brought to the emergency room after the crash of his private plane. 125. Everything he ate before the operation but will avoid those foods that cause gas C. Maintain sterility of the ventilation system C. The most immediate nursing intervention for him at this time would be to: A. Prepare him for emergency surgery Answer: (C) Assess his response to the equipment It is a primary nursing responsibility to evaluate effect of interventions done to the client. Bland foods so that his intestines do not become irritated D. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen.

Complete safety of the procedure B. . Milk the tube toward the collection container as ordered C. and improves pulmonary function 129. Clam the tube immediately Answer: (B) Milk the tube toward the collection container as ordered This assists in moving blood. The most appropriate nursing action would be to A. toward the collection chamber 128. Blood pressure readings of 50/30 and 70/40 within 30 minutes Answer: (A) Urinary output is 30 ml in an hour A rate of 30 ml/hr is considered adequate for perfusion of kidney. Crepitus detected on palpation of chest D. heart and brain. which may be obstructing drainage. the nurse should emphasize in his teaching plan the: A. Prepare for chest tube removal B. Urinary output is 30 ml in an hour B. In the evaluation of a client’s response to fluid replacement therapy. fluid or air. Increased breath sounds B. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is: A. Arrange for a stat Chest x-ray film. Constant bubbling in the drainage chamber C.127. In preparing the client for surgery. drains fluid and air from the pleural space. Risk of the procedure with his other injuries D. He begins to complain of increased abdominal pain in the left upper quadrant. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later. Expectation of postoperative bleeding C. Central venous pressure reading of 2 cm H2O C. Presence of abdominal drains for several days after surgery Answer: (D) Presence of abdominal drains for several days after surgery Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation. Pulse rates of 120 and 110 in a 15 minute period D. Increased respiratory rate Answer: (A) Increased breath sounds The chest tube normalizes intrathoracic pressure and restores negative intrapleural pressure. A client with multiple injury following a vehicular accident is transferred to the critical care unit. D. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. the client’s chest tube seems to be obstructed. the observation that indicates adequate tissue perfusion to vital organs is: A. 130.

Sublimation C. Emphasize repeatedly that with as prosthesis. Acceptance of the client’s behavior is an important factor in the nurse’s intervention. Continue observing for dyspnea and crepitus Answer: (B) Encourage frequent coughing and deep breathing This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange. The best initial nursing approach would be to: A. talk or perform any rehabilitative activities. 133. Three days postoperatively. Obviousness of the change D. Encourage frequent coughing and deep breathing C. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture. 134. Appear cheerful and non-critical regardless of his response to attempts at intervention D. Give him explanations of why there is a need to quickly increase his activity B. Turn him from side to side at least every 2 hours D. he will be able to return to his normal lifestyle C. The key factor in accurately assessing how body image changes will be dealt with by the client is the: A. Reaction formation B.131. but the client’s feeling about the change that is the most important determinant of the ability to cope. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. the nurse should: A. Projection . Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. 132. A client undergoes below the knee amputation following a vehicular accident. Suddenness of the change C. Encourage bed rest with active and passive range of motion exercises B. Intellectualization D. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Client’s perception of the change Answer: (D) Client’s perception of the change It is not reality. The nurse recognizes that Larry is using the defense mechanism known as: A. Extent of body change present B. the client is refusing to eat. The client should be encouraged to his feelings.

Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets. Dennis receives a blood transfusion and develops flank pain. Use a soft toothbrush and electric razor Answer: (D) Use a soft toothbrush and electric razor Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia. Agree with and encourage the client’s denial B.Answer: (C) Intellectualization People use defense mechanisms to cope with stressful events. In dealing with a dying client who is in the denial stage of grief. Leave the client alone to discuss the loss Answer: (C) Allow the denial but be available to discuss death This does not take away the client’s only way of coping. An anaphylactic transfusion reaction B. Sleep with the head of his bed slightly elevated C. An allergic transfusion reaction C. decreased platelets. chills. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to: A. thus the flank pain and hematuria and the other manifestations. “He who laughs on the outside. 135.” C. Allow the denial but be available to discuss death D. Increase his activity level and ambulate frequently B.” B. and it permits future . A pyrogenic transfusion reaction Answer: (C) A hemolytic transfusion reaction This results from a recipient’s antibodies that are incompatible with transfused RBC’s. Reassure the client that everything will be okay C. Drink citrus juices frequently for nourishment D. agglutination. “Your laugher is a cover for your fear. Anemia and leucopenia are the two other problems noted with bone marrow depression. 138. The nurse recognizes that Dennis is probably experiencing: A. the best nursing approach is to: A. these signs result from RBC hemolysis. The nurse’s most therapeutic response would be: A. A hemolytic transfusion reaction D. “Does it help you to joke about your illness?” Answer: (D) “Does it help you to joke about your illness?” This non-judgmentally on the part of the nurse points out the client’s behavior. cries on the inside. A client jokes about his leukemia even though he is becoming sicker and weaker. also called type II hypersensitivity. “Why are you always laughing?” D. and capillary plugging that can damage renal function. fever and hematuria. 137. 136.

2 lbs. +485 ml Answer: (C) +235 ml The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid. resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion. a vasodilator. Ascending limb of the loop of Henle Answer: (D) Ascending limb of the loop of Henle This is the site of action of Lasix being a potent loop diuretic.5 L B. +55 ml B. Crushing chest pain B.5 L Answer: (C) 2. Glomerulus of the nephron D. Mario drinks two 6 oz. +137 ml C. 142. cups of tea and vomits 125 ml of fluid. Distal tubule B. 2. Mr. Mr. The nurse understands Lasix exerts is effects in the: A. Collecting duct C. +235 ml D. Ong weighs 210 lbs on admission to the hospital. Extensive peripheral edema D. the nurse should expect to find: A.0 L D. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages. After 2 days of diuretic therapy he weighs 205. The physician orders on a client with CHF a cardiac glycoside. Therefore a 4. Jugular vein distention Answer: (B) Dyspnea on exertion Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed. The nurse could estimate that the amount of fluid he has lost is: A. 139. During this 8 hour period.0 L One liter of fluid weighs approximately 2. his fluid balance would be: A. and furosemide (Lasix). 141. In the assessment. 0. . 1. During and 8 hour shift. loss is subtracted from intake 140.0 L C. Dyspnea on exertion C.5 lbs weight loss equals approximately 2 Liters. 3.5 lbs.movement through the grieving process when the client is ready. Ong is admitted to the hospital with a diagnosis of Left-sided CHF.

The nurse understands that this diet contains approximately: A. 1600 calories Answer: (B) 2000 calories There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein 145. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates. Potassium D. 90 g of fat and 100 g of protein. irritate the stomach lining and may cause bleeding with prolonged use 147. 144. such as aspirin and prednisone. His working patterns Answer: (A) The medications he has been taking Some medications. The medications he has been taking B. Vasodilator C. Mr. 2000 calories C. 2200 calories B. Ong. After the acute phase of congestive heart failure. Cardiac glycoside Answer: (D) Cardiac glycoside A cardiac glycoside such as digitalis increases force of cardiac contraction. Jude develops GI bleeding and is admitted to the hospital. Diuretic B.143. 2800 calories D. decreases the conduction speed of impulses within the myocardium and slows the heart rate. Magnesium B. The nurse concludes that his pulse rate is most likely the result of the: A. the nurse should expect the dietary management of the client to include the restriction of: A. His apical pulse rate is 44 and he is on bed rest. His usual dietary pattern D. Any recent foreign travel C. Sodium C. has been receiving a cardiac glycoside. and a vasodilator drug. a client with CHF. The meal pattern that would probably be most appropriate for a client . Bed-rest regimen D. a diuretic. An important etiologic clue for the nurse to explore while taking his history would be: A. Calcium Answer: (B) Sodium Restriction of sodium reduces the amount of water retention that reduces the cardiac workload 146.

Limited food and fluid intake when he has pain D. Three large meals large enough to supply adequate energy. Increasing HCO3 B. A flexible plan according to his appetite Answer: (B) Regular meals and snacks to limit gastric discomfort Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Decreasing pH D. Massaging gently the legs with lotion D. Following surgery. 600 Kilocalories C. urinary infection is a . Thrombus formation is a danger for all postoperative clients. Applying elastic stockings C. 149. 400 Kilocalories B. all of which lead to thrombus formation. He begins to hyperventilate. only about a third of the basal energy need. the client has a nasogastric tube to low continuous suction. Regular meals and snacks to limit gastric discomfort C.recovering from GI bleeding is: A. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon 151. therefore 3L x 50 g/L x 4 kcal/g = 600 kcal. IV fluids are started and a Foley catheter is inserted. An unconscious client is admitted to the ICU. B. 3 L per day would apply approximately: A. Decreasing PO2 Answer: (B) Decreasing PCO2 Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis. Decreasing PCO2 C. hypercoagulability. The nurse should be aware that this pattern will alter his arterial blood gases by: A. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Mucosal irritation can lead to bleeding. 148. The nurse should act independently to prevent this complication by: A. 800 Kilocalories D. 150. 1000 Kilocalories Answer: (B) 600 Kilocalories Carbohydrates provide 4 kcal/ gram. Because 1 L of a 5% dextrose solution contains 50 g of sugar. Performing active-assistive leg exercises Answer: (D) Performing active-assistive leg exercises Inactivity causes venous stasis. and external pressure against the veins. Encouraging adequate fluids B. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. With an indwelling catheter.

Urinary control may be permanently lost to some degree B. Pronation. adduction and extension C. Rene. 155. Urinary drainage will be dependent on a urethral catheter for 24 hours C. His ability to perform sexually will be permanently impaired Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours An indwelling urethral catheter is used. the torso tends to slide and causes this phenomenon. Assessing urine specific gravity Answer: (C) Maintaining the ordered hydration Promoting hydration. supination. extension and left and right rotation B. The nurse understands that to prevent the effects of shearing force on the skin. the nurse must perform: A. 30 degrees B. 90 degrees Answer: (A) 30 degrees Shearing force occurs when 2 surfaces move against each other. Emptying the drainage bag frequently B. age 62. Shearing forces are good contributory factors of pressure sores. 154. eversion and inversion These movements include all possible range of motion for the ankle joint 153. Frequency and burning on urination will last while the cystotomy tube is in place D. flexion. When putting his ankle through range of motion. Following surgery. nursing care should include: . The nurse can best plan to avoid this problem by: A. the head of the bed should be at an angle of: A. Collecting a weekly urine specimen C. plantar flexion. Abduction. The transurethral resection of the prostate is performed on a client with BPH. when the bed is at an angle greater than 30 degrees. As part of the preoperative teaching. The nurse performs full range of motion on a bedridden client’s extremities. and extension D. plantar flexion. Maintaining the ordered hydration D. maintains urine production at a higher rate. Dorsiflexion. 60 degrees D. eversion and inversion Answer: (D) Dorsiflexion. is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). the nurse should tell the client that after surgery: A.potential danger. A client has been in a coma for 2 months. rotation. 45 degrees C. which flushes the bladder and prevents urinary stasis and possible infection 152. because surgical trauma can cause urinary retention leading to further complications such as bleeding. Flexion.

This is done to: A. Irrigate the catheter with saline B. Twenty-four hours after TURP surgery. Sepsis B. Changing the abdominal dressing B. hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed. Promote urinary drainage Answer: (B) Provide hemostasis The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding. the most common complication the nurse should observe for is: A. Call the physician if my urinary stream decreases . Observing for hemorrhage and wound infection Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis Patency of the catheter promotes bladder decompression. Following prostate surgery. 159. the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. Reduce bladder spasms D. Maintaining patency of a three-way Foley catheter for cystoclysis D. In the early postoperative period following a transurethral surgery. the client tells the nurse he has lower abdominal discomfort. which prevents distention and bleeding. Provide hemostasis C. Notify the physician Answer: (B) Milk the catheter tubing Milking the tubing will usually dislodge the plug and will not harm the client. Leakage around the catheter D. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis 156.A. Maintaining patency of the cystotomy tube C. Get out of bed into a chair for several hours daily B. Limit discomfort B. Milk the catheter tubing C. A physician’s order is not necessary for a nurse to check catheter patency. Hemorrhage C. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:” A. 157. Urinary retention with overflow Answer: (B) Hemorrhage After transurethral surgery. The nurse’s initial action should be to: A. The nurse notes that the catheter drainage has stopped. Remove the catheter D. 158.

163. Checking her throat for swelling C. Asking her to state her name out loud D. A small part of the gland is left intact C. nerve damage. subcutaneous bleeding that presses on the trachea. A tracheostomy set and oxygen C. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. Total thyroidectomy is generally done in clients with Thyroid Ca. Attempt to void every 3 hours when I’m awake D. 162. the nurse would consider that in a subtotal thyroidectomy: A. One parathyroid gland is also removed D.C. When assessing Lucy. the nurse would expect to find: A. She is diagnosed with Grave’s Disease. exopthalmos and restlessness Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. and lethargy C. In planning for the client’s return from the OR. Weight loss. A crash cart with bed board B. The entire thyroid gland is removed B. A portion of the thyroid and four parathyroids are removed Answer: (B) A small part of the gland is left intact Remaining thyroid tissue may provide enough hormone for normal function.thyroidectomy client returns to her room from the OR. and forgetfulness B. the nurse plans to set up emergency equipment. Avoid vigorous exercise for 6 months after surgery Answer: (B) Call the physician if my urinary stream decreases Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction. which should include: A. and weight gain Answer: (C) Weight loss. the client will be . 160. Two ampules of sodium bicarbonate Answer: (B) A tracheostomy set and oxygen Acute respiratory obstruction in the post-operative period can result from edema. Exopthalmos is due to peribulbar edema. weight gain. protruding eyeballs. Observing for signs of tetany B. exopthalmos and restlessness D. Weight loss. Palpating the side of her neck for blood seepage Answer: (C) Asking her to state her name out loud If the recurrent laryngeal nerve is damaged during surgery. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by: A. 161. Lethargy. An airway and rebreathing mask D. Constipation. Before a post. dry skin. or tetany.

The nurse teaches her how to reduce discomfort and prevent corneal ulceration. 4. 166. The nurse applies mafenide acetate (Sulfamylon cream) to Clara. On a post-thyroidectomy client’s discharge. who has second and third degree burns on the right upper and lower extremities. Clara is a 37-year old cook.5% giving a total of 22.5% Answer: (D) 22.hoarse and have difficult speaking.5% 167. Avoid moving my extra-ocular muscles C. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops: A. Dry skin and fatigue C. Inhibit bacterial growth . This medication will: A. 165. Insomnia and excitability Answer: (B) Dry skin and fatigue Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. and she is in pain and anxious. Progressive weight loss D. 22. the nurse teaches her to observe for signs of surgically induced hypothyroidism. Performing an immediate appraisal. 164. Her respiratory status is compromised. 9% C. Intolerance to heat B. the nurse estimates the percent of Clara’s body surface that is burned is: A. Avoid using a sleeping mask at night D. as ordered by the physician. using the rule of nines. Body functions and metabolism are decreased in hypothyroidism. Avoid excessive blinking Answer: (C) Avoid using a sleeping mask at night The mask may irritate or scratch the eye if the client turns and lies on it during the night.5% The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4. She is admitted for treatment of partial and fullthickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. The nurse recognizes that the client understands the teaching when she says: “I should: A.5% B. 18 % D. Elevate the head of my bed at night B.

a 20.B. These grafts will: A. The drop factor of the tubing is 10 gtt/ml. which reduces pain and provides a framework for granulation that promotes effective healing. Supine position Answer: (C) Orthopneic position The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion 171. Be sutured in place for better adherence C. a burn client. 28 gtt/min C. She is scheduled to have a series of diagnostic studies for myasthenia gravis. 18 gtt/min B.year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. including a Tensilon test. 32 gtt/min D. Forty-eight hours after a burn injury. Orthopneic position D. Relieve pain and promote rapid epithelialization D. Jane. the physician orders for the client 2 liters of IV fluid to be administered q12 h. multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 169. 170. Prevent scar tissue formation D. Clara. receives a temporary heterograft (pig skin) on some of her burns. the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: A. Provide chemical debridement Answer: (A) Inhibit bacterial growth Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes 168. Relieve pain from the burn C. Sims’ position C. Frequently be used concurrently with topical antimicrobials. 36 gtt/min Answer: (B) 28 gtt/min This is the correct flow rate. Answer: (C) Relieve pain and promote rapid epithelialization The graft covers nerve endings. In preparing her for this procedure. The position that would provide for the greatest respiratory capacity would be the: A. Semi-fowler’s position B. A client with burns on the chest has periodic episodes of dyspnea. Debride necrotic epithelium B. Prolonged symptomatic improvement . The nurse should set the flow to provide: A. Brief exaggeration of symptoms B.

172. Respiratory exchange and ability to swallow Answer: (D) Respiratory exchange and ability to swallow Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration 174. Evaluate the client’s emotional side effects between doses Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours. Develop a teaching plan B. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: A. Ability to chew and speak distinctly B. The Mestinon dosage is frequently changed during the first week. the response will influence dosage levels. Maintain the present muscle strength D. Administer the medication with food or mild C. The most significant initial nursing observations that need to be made about a client with myasthenia include: A. begins to experience increased difficulty in swallowing. Administer the medication exactly on time B. with a peak effect in 30 seconds.C. Coordinate her meal schedule with the peak effect of her medication. Facilitate psychologic adjustment C. Ability to smile an to close her eyelids D. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. To prevent aspiration of food. Rapid but brief symptomatic improvement D. the nursing action that would be most effective would be to: A. Place an emergency tracheostomy set in her room C. Symptomatic improvement of just the ptosis Answer: (C) Rapid but brief symptomatic improvement Tensilon acts systemically to increase muscle strength. Mestinon . Assess her respiratory status before and after meals D. Degree of anxiety about her diagnosis C. Prepare for the appearance of myasthenic crisis Answer: (C) Maintain the present muscle strength Until diagnosis is confirmed. It lasts several minutes. Change her diet order from soft foods to clear liquids B. primary goal should be to maintain adequate activity and prevent muscle atrophy 173. a client with myasthenia gravis. 175. Helen. Evaluate the client’s muscle strength hourly after medication D. While the dosage is being adjusted. the nurse’s priority intervention is to: A.

Hacks. thereby decreasing the probability of aspiration.Forum for Nurses!  Book Of Tips . Wednesday. All rights reserved. Article copyright NurseReview. . No part of an article may be reproduced without the prior permission. Mestinon Dysphagia should be minimized during peak effect of Mestinon.Org .Tips. you may want to subscribe to my RSS feed.org .NurseReview.#1 source of information to update nurses all over the world. and more. November 19. One advantage of subscribing to RSS feeds is that you don't have to constantly re-visit this site to .Related Nursing Articles charted by Online NLE Reviewer 0 comments Labels: NURSING ONLINE READINESS TEST: NLE REVIEW Bookmark this post:  Job Search for Nurses RN/LVN  Forum. Tricks. 2008 Maternity Nursing: Nursing Online Readiness Test (Review For NLE November 2008 PRC) If you're new here.Answer: (D) Coordinate her meal schedule with the peak effect of her medication. Mestinon can increase her muscle strength including her ability to swallow.

Estrogen B. The mass palpated is the buttocks. Enjoy! If you like this post. The mass palpated at the fundal part is the head part. When the mass palpated is hard round and movable. The best site is the fetal back nearest the head. The mass palpated is the head. The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the mass. In Leopold’s maneuver step # 3 you palpated a hard round movable mass at the supra pubic area. The hormone responsible for a positive pregnancy test is: A. D. The correct interpretation of this finding is: A. In Leopold’s maneuver step #1. WRONG RATIONALE. The mass is the fetal back. The mass palpated is the back D. Left lower quadrant B. C. 2. it is the fetal head. The buttocks because the presentation is breech. NurseReview. USE THIS AT YOUR DESGRESSION 1. 4. The landmark to look for when looking for PMI is the location of the fetal back in relation to the right or left side of the mother and the presentation. 3. Follicle Stimulating hormone .check for updates within specific sections you might be interested in because your browser or Feed reader will do this for you automatically on a regular basis plus you can even get email notification. The correct interpretation is that the mass palpated is: A. You performed the leopold’s maneuver and found the following: breech presentation. MATERNITY NURSING NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB. B. you palpated a soft broad mass that moves with the rest of the mass. Human Chorionic Gonadotropin D. WRONG ANSWERS. whether cephalic or breech. Digg It! Click on the Digg button. Left upper quadrant D. fetal back at the right side of the mother. Based on these findings. Thank you so much. ETC. C. INCONSISTENCIES. The mass palpated is the fetal small part Answer: (B) The mass palpated is the head. The presentation is breech. Progesterone C.Org IS NOT RESPONSIBLE FOR ANY TYPOS. Right upper quadrant Answer: (B) Right lower quadrant Right lower quadrant. B. Answer: (D) The mass palpated is the buttocks.. you can hear the fetal heart beat (PMI) BEST in which location? A. Right lower quadrant C.

the fetus can’t be delivered normally per vagina. None of the above Answer: (B) Vertical position Vertical position means the fetal spine is parallel to the maternal spine thus making it easy for the fetus to go out the birth canal. The hormone responsible for the maturation of the graafian follicle is: A. Oblique position D. Estrogen D. The woman is having allergic reaction to the pregnancy and its hormones D. . A normal occurrence in pregnancy because the fetus is using more oxygen B. the lungs have reduced space for expansion consequently reducing the oxygen supply. This complaint maybe explained as: A. 7. If transverse or oblique. Luteinizing hormone Answer: (A) Follicle stimulating hormone The hormone that stimulates the maturation if the of the graafian follicle is the Follicle Stimulating Hormone which is released by the anterior pituitary gland. The urinary frequency is caused by the compression of the urinary bladder by the gravid uterus which is still within the pelvic cavity during the first trimester. In the later part of the 3rd trimester. Transverse position B. The fundus of the uterus is high pushing the diaphragm upwards C. and presence of striae gravidarum B. the fundus of the enlarged uterus is pushing the respiratory diaphragm upwards. Vertical position C. while the placenta is not yet fully developed. 5.Answer: (C) Human Chorionic Gonadotropin Human chorionic gonadotropin (HCG) is the hormone secreted by the chorionic villi which is the precursor of the placenta. The most common normal position of the fetus in utero is: A. 9. the major hormone that sustains the pregnancy is HCG. Fullness of the breast and urinary frequency C. In the early stage of pregnancy. Increased respiratory rate and ballottement Answer: (B) Fullness of the breast and urinary frequency Fullness of the breast is due to the increased amount of progesterone in pregnancy. Follicle stimulating hormone B. 8. Weight gain of 6-10 lbs. Progesterone C. Thus. the mother may experience shortness of breath. Braxton Hicks contractions and quickening D. Which of the following findings in a woman would be consistent with a pregnancy of two months duration? A. The woman maybe experiencing complication of pregnancy Answer: (B) The fundus of the uterus is high pushing the diaphragm upwards From the 32nd week of the pregnancy.

Lightening B. the correct nursing intervention to relieve the muscle cramps is: A. a healthy mother should have prenatal check up every: A. Backache B. (+) pregnancy test D. Nausea Answer: (A) Backache Backache usually occurs in the lumbar area and becomes more problematic as the uterus enlarges. 11. 14. Let the woman lie down and dorsiflex the foot towards the knees D. In early pregnancy. Let the woman walk for a while C. Shoes with low. the fetus is moving but too weak to be felt by the mother. In the 18th-20th week of gestation. 12. (+) ultrasound Answer: (D) (+) ultrasound A positive ultrasound will definitely confirm that a woman is pregnant since the fetus in utero is directly visualized. Fetal movement felt by mother B. Leg cramps D. the intervention is to stretch the muscle by dosiflexing the foot of the affected leg towards the knee. Enlargement of the uterus C. broad heels. week B. Vertigo C.10. 2 weeks C. the fetal movements become stronger thus the mother already feels the movements. What event occurring in the second trimester helps the expectant mother to accept the pregnancy? A. 13. The pregnant woman in her third trimester usually assumes a lordotic posture to maintain balance causing an exaggeration of the lumbar curvature. Which of the following is a positive sign of pregnancy? A. When a pregnant woman experiences leg cramps. Ask the woman to raise her legs Answer: (C) Let the woman lie down and dorsiflex the foot towards the knees Leg cramps is caused by the contraction of the gastrocnimeus (leg muscle). Quickening Answer: (D) Quickening Quickening is the first fetal movement felt by the mother makes the woman realize that she is truly pregnant. Low broad heels provide the pregnant woman with a good support. Allow the woman to exercise B. plus a good posture will prevent which prenatal discomfort? A. Ballotment C. 3 weeks . Thus. Pseudocyesis D. From the 33rd week of gestation till full term.

The expected weight gain in a normal pregnancy during the 3rd trimester is A. Quickening C. one pound a week is expected. 24 C. The following are ways of determining expected date of delivery (EDD) when the LMP is unknown EXCEPT: A. Batholomew’s rule of 4 Answer: (A) Naegele’s rule Naegele’s Rule is determined based on the last menstrual period of the woman. If the LMP is Jan. when the level of the fundus is midway between the umbilicus and xyphoid process the estimated age of gestation (AOG) is: A. Nov. Oct. 10 lbs total weight gain in the 3rd trimester Answer: (A) 1 pound a week During the 3rd trimester the fetus is gaining more subcutaneous fat and is growing fast in preparation for extra uterine life. Mc Donald’s rule D. 30. 7 D. the expected date of delivery (EDD) is A. the landmarks used are the symphysis pubis. 16. umbilicus and xyphoid process. In the Batholonew’s rule of 4. Nov. 7 B. Thus. 7 Based on the last menstrual period. 4 weeks Answer: (A) week In the 9th month of pregnancy the mother needs to have a weekly visit to the prenatal clinic to monitor fetal condition and to ensure that she is adequately prepared for the impending labor and delivery. 8th month Answer: (C) 7th month In Bartholomew’s Rule of 4. The formula for the Naegele’s Rule is subtract 3 from the month and add 7 to the day. Naegele’s rule B. 5th month B.D. 15. the expected date of delivery is Nov. 8 Answer: (C) Nov. 6th month C. 7th month D. the AOG is approximately 5 months and at the level of the xyphoid process 9 months. Oct. 7. midway between these two landmarks would be considered as 7 months AOG. Thus. 1 pound a week B. 2 pounds a week C. . At the level of the umbilicus. 18. 10 lbs a month D. 17.

When the first fetal movement is felt B. minerals and vitamins B. Relieve backache C. The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow B. Proteins. phosphorous. The diet that is appropriate in normal pregnancy should be high in A. Carbohydrates and vitamins C. iodine. zinc.19. B. 21. The main reason for an expected increased need for iron in pregnancy is: A. magnesium) because of the need of the growing fetus. Urinary frequency C. No fetal movement is felt on the 6th month C. The mother may have a problem of digestion because of pica Answer: (A) The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow About 400 mgs of Iron is needed by the mother in order to produce more RBC mass to be able to provide the needed increase in blood supply for the fetus. 22. about 350-400 mgs of iron is need for the normal growth of the fetus. minerals and vitamins In normal pregnancy there is a higher demand for protein (body building foods). Mild uterine contraction . Thus. Prevent leg varicosities and edema Answer: (A) Strengthen perineal muscles Kegel’s exercise is done by contracting and relaxing the muscles surrounding the vagina and anus in order to strengthen the perineal muscles 20. The fetus has an increased need for RBC which the mother must supply D. Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort? A. Pelvic rocking is good to relieve backache. iron. Strengthen perineal muscles B. folic acid) and minerals (esp. 24. C. carbohydrates and fats D. vitamin A. Backache Answer: (D) Backache Backache is caused by the stretching of the muscles of the lower back because of the pregnancy. Kegel’s exercise is done in pregnancy in order to: A. Which of the following signs will require a mother to seek immediate medical attention? A. Fats and minerals Answer: (A) Protein. The mother may suffer anemia because of poor appetite C. Also. Orthostatic hypotension D. vitamins (esp. calcium. Strengthen abdominal muscles D. Protein. about 750-800 mgs iron supplementation is needed by the mother to meet this additional requirement. Leg cramps B.

You prepare your client for the procedure by: A. Taking her vital signs and recording the readings C. Observe NPO from midnight to avoid vomiting B. Dry carbohydrate food like crackers B. If the pregnancy is already in its 6th month and no fetal movement is felt. Giving the client a perineal care D. Intravenous infusion D. Lower uterine segment D. the pregnancy is not normal either the fetus is already dead intra-uterine or it is an H-mole. Lower cervical segment . 27. 28. You want to perform a pelvic examination on one of your pregnant clients. The common normal site of nidation/implantation in the uterus is A. When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done D. The nursing intervention to relieve “morning sickness” in a pregnant woman is by giving A. Slight dyspnea on the last month of gestation Answer: (B) No fetal movement is felt on the 6th month Fetal movement is usually felt by the mother during 4. the manipulation may cause discomfort and accidental urination because of the pressure applied during the abdominal palpation. A full bladder is needed when doing an abdominal ultrasound to serve as a “window” for the ultrasonic sound waves to pass through and allow visualization of the uterus (located behind the urinary bladder).D. Antacid Answer: (A) Dry carbohydrate food like crackers Morning sickness maybe caused by hypoglycemia early in the morning thus giving carbohydrate food will help. Upper uterine portion B. If the pregnant woman has a full bladder. Void immediately before the procedure for better visualization Answer: (C) Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done Drinking at least 2 liters of water 2 hours before the procedure will result to a distended bladder. 26. Also. Low sodium diet C. the nurse should instruct her to: A. Mid-uterine area C. Doing a vaginal prep Answer: (A) Asking her to void A pelvic examination includes abdominal palpation. a full bladder can impede the accuracy of the examination because the bladder (which is located in front of the uterus) can block the uterus. 25. Do perineal flushing properly before the procedure C. Asking her to void B.5 – 5 months.

Which of the following statements is TRUE of conception? A.Cushions the fetus from abdominal trauma 2. 30. Chloasma B. fertilization is possible. All of the above Answer: (D) All of the above All the four functions enumerated are true of amniotic fluid.Answer: (A) Upper uterine portion The embryo’s normal nidation site is the upper portion of the uterus. 4 C. She is considered to be A. The following are skin changes in pregnancy EXCEPT: A. Which of the following are the functions of amniotic fluid? 1. 1. she would be considered Para 3. Para refers to the number of pregnancies that have reached viability. Striae gravidarum C.Facilitates fetal movement A. G 5 P 3 C. fertilization is possible 4 days after ovulation C. Conception is possible during menstruation in a long menstrual cycle D. Mrs. G 4 P 3 B. Thus. intercourse must be avoided 5 days before and 3 days after menstruation Answer: (A) Within 2-4 hours after intercourse conception is possible in a fertile woman The sperms when deposited near the cervical os will be able to reach the fallopian tubes within 4 hours. Twin pregnancy is counted only as 1. Chadwick's sign Answer: (D) Chadwick's sign Chadwick's sign is bluish discoloration of the vaginal mucosa as a result of the increased vascularization in the area. Generally. 2. To avoid conception.Serves as the fluid for the fetus 3. 1. 3. 1 & 3 B. this is an abnormal condition called placenta previa. 32. G 5 P 4 D. 31. 3 D. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy and the first pregnancy was a twin. . If the woman has just ovulated (within 24hours after the rupture of the graafian follicle). If the implantation is in the lower segment. G 4 P 4 Answer: (B) G 5 P 3 Gravida refers to the total number of pregnancies including the current one. if the woman has had one abortion. 29. Within 2-4 hours after intercourse conception is possible in a fertile woman B. Linea negra D.Maintains the internal temperature 4.

The smoke will make the fetus and the mother feel dizzy D. Hemoglobin is needed to supply the fetus with adequate oxygen. Hemorrhage C. Large for gestational age (LGA) fetus B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus C. You are performing abdominal exam on a 9th month pregnant woman. Which of the following signs and symptoms will most likely make the nurse suspect that the patient is having hydatidiform mole? A. 37. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus. tachycardia. Going into shock Answer: (B) Having supine hypotension Supine hypotension is characterized by breathlessness. Having sudden elevation of BP D. Having supine hypotension C. last menstrual period (LMP) 5 months ago. fetal heart beat . Oxygen is needed for normal growth and development of the fetus. and cold clammy skin. Erythroblastosis fetalis Answer: (C) Small for gestational age (SGA) baby Anemia is a condition where there is a reduced amount of hemoglobin.33. Absence of fetal heart beat D. she felt breathless. 35. Small for gestational age (SGA) baby D. Passage of clear vesicular mass per vagina C. Nicotine causes vasodilation of the mother’s blood vessels B. pallor. 36. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus. Enlargement of the uterus Answer: (B) Passage of clear vesicular mass per vagina Hydatidiform mole (H-mole) is characterized by the degeneration of the chorionic villi wherein the villi becomes vesicle-like. 34. Experiencing the beginning of labor B. This is due to the compression of the abdominal aorta by the gravid uterus when the woman is on a supine position. Which of the following is the most likely effect on the fetus if the woman is severely anemic during pregnancy? A. The correct assessment of the woman’s condition is that she is A. These vesicle-like substances when expelled per vagina and is a definite sign that the woman has H-mole. Smoking is contraindicated in pregnancy because A. Slight bleeding B. had pallor. tachycardia and cold clammy skin. While lying supine. Nicotine will cause vasoconstriction of the fetal blood vessels Answer: (B) Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus Carbon monoxide is one of the substances found in cigarette smoke.

Apply restraint so that the patient will not fall out of bed B. Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back C. Which of the following is the most possible diagnosis of this condition? A. An emergency delivery set for vaginal delivery must be made ready before examining the patient D. not in labor.(FHB) not appreciated. 40. Also. Putting a mouth gag is not safe since during the convulsive seizure the jaw will immediately lock. the pregnancy is only 5 months but the size of the uterus is already above the umbilicus which is compatible with 7 months AOG. Check if the woman is also having a precipitate labor Answer: (C) Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration Positioning the mother on her side will allow the secretions that may accumulate in her mouth to drain by gravity thus preventing aspiration pneumonia. Prevent perinatal infection D. Since the heart of a gravido-cardiac is compromised. The preferred manner of delivering the baby is vaginal C. Missed abortion C. Allow the fetus to achieve normal intrauterine growth B. Ectopic pregnancy Answer: (A) Hydatidiform mole Hydatidiform mole begins as a pregnancy but early in the development of the embryo degeneration occurs. Position the mother on her side to allow the secretions to drain from her mouth and prevent aspiration D. The nurse must always consider which of the following precautions: A. Reduce incidence of premature labor Answer: (B) Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother Activity of the mother will require more oxygen consumption. Pelvic inflammatory disease D. Hydatidiform mole B. there is a need to put a mother on bedrest to reduce the need for oxygen. 39. check the perineum for signs of precipitate labor. The mother may go into labor also during the seizure but the immediate concern of the nurse is the safety of the baby. Minimize oxygen consumption which can aggravate the condition of the compromised heart of the mother C. A gravido-cardiac mother is advised to observe bedrest primarily to A. After the seizure. A pregnant mother is admitted to the hospital with the chief complaint of profuse vaginal bleeding. no fetal heart beat is appreciated because the pregnancy degenerated thus there is no appreciable fetal heart beat. When a pregnant woman goes into a convulsive seizure. In the situation given. The internal exam is done only at the delivery under strict asepsis with a double set-up B. Internal exam must be done following routine procedure . 38. The proliferation of the vesicle-like substances is rapid causing the uterus to enlarge bigger than the expected size based on ages of gestation (AOG). AOG 36 wks. the MOST immediate action of the nurse to ensure safety of the patient is: A.

Any of the above Answer: (B) Put the mother on left side lying position When a pregnant woman lies on supine position. The drugs commonly given are: A. Prostaglandin and oxytocin C. Presence of uterine contraction Answer: (B) Dilation of the cervix In imminent abortion. The nursing measure to relieve fetal distress due to maternal supine hypotension is: A. To prevent preterm labor from progressing. the weight of the gravid uterus would be compressing on the vena cava against the vertebrae obstructing blood flow from the lower extremities. A double set-up means there is a set up for cesarean section and a set-up for vaginal delivery to accommodate immediately the necessary type of delivery needed. Put the mother on left side lying position C. Hence. 44. the placenta is found at the: . Which of the following signs will distinguish threatened abortion from imminent abortion? A. strict asepsis must be observed. the pregnancy will definitely be terminated because the cervix is already open unlike in threatened abortion where the cervix is still closed. Place the mother on semi-fowler’s position B. 42.Answer: (A) The internal exam is done only at the delivery under strict asepsis with a double set-up Painless vaginal bleeding during the third trimester maybe a sign of placenta praevia. Magnesium sulfate and terbutaline B. If internal examination is done in this kind of condition. immediate vaginal delivery may still be possible so the set up for vaginal delivery will be used. This causes a decrease in blood return to the heart and consequently immediate decreased cardiac output and hypotension. 43. Place mother on a knee chest position D. In both cases. this can lead to even more bleeding and may require immediate delivery of the baby by cesarean section. In placenta praevia marginalis. Progesterone and estrogen D. If the bleeding is due to soft tissue injury in the birth canal. Severity of bleeding B. putting the mother on side lying will relieve the pressure exerted by the gravid uterus on the vena cava. oxytocin and prostaglandin stimulates contraction of smooth muscles. Terbutaline is a drug that inhibits the uterine smooth muscles from contracting. Nature and location of pain D. drugs are usually prescribed to halt the labor. 41. Dilation of the cervix C. Dexamethasone and prostaglandin Answer: (A) Magnesium sulfate and terbutaline Magnesium sulfate acts as a CNS depressant as well as a smooth muscle relaxant. On the other hand.

Gonorrhea. Candidiasis D. candidiasis and moniliasis are conditions that can affect the fetus as it passes through the vaginal canal during the delivery process. Chicken pox D. Which of the following causes of infertility in the female is primarily psychological in origin? A. Vaginismus B. German measles B. Rubella Answer: (B) Orchitis Orchitis is a complication that may accompany mumps in adult males. Lower portion of the uterus completely covering the cervix Answer: (C) Lower segment of the uterus with the edges near the internal cervical os Placenta marginalis is a type of placenta previa wherein the placenta is implanted at the lower segment of the uterus thus the edges of the placenta are touching the internal cervical opening/os. In which of the following conditions can the causative agent pass through the placenta and affect the fetus in utero? A. Cervix B. 48. Lower segment of the uterus with the edges near the internal cervical os D. It can’t detect cancer in ovaries and fallopian tubes because these organs are outside of the uterus and the abnormal cells from these organs will not be detected from a smear done on the cervix. Which of the following can lead to infertility in adult males? A. The normal site of placental implantation is the upper portion of the uterus. Papanicolaou smear is usually done to determine cancer of A. 47. Dyspareunia . Breast Answer: (A) Cervix Papanicolaou (Paps) smear is done to detect cervical cancer. Rubella C. 46. moniliasis Answer: (B) Rubella Rubella is caused by a virus and viruses have low molecular weight thus can pass through the placental barrier. Ovaries C. Fallopian tubes D. External cervical os slightly covering the opening C. Gonorrhea B.A. 45. About 20-30% of males who gets mumps after puberty may develop this complication. Internal cervical os partly covering the opening B. Orchitis C. This condition is characterized by unilateral inflammation of one of the testes which can lead to atrophy of the affected testis.

the fetus will not be affected D. the fetus will not be affected On the first pregnancy. the mother still has no contact with Rh(+) blood thus it has not antibodies against Rh(+). The fetus takes it’s blood type usually form the father. urine output in 4 hours B. the baby will suffer from chronic hypoxia leading to a small-for-gestational age condition. when the heart is compromised such as in maternal cardiac condition. Dyspareunia is usually caused by infection. The condition can occur if the mother is Rh(+) and the fetus is Rh(-) B. Endometriosis D. Which of the following is TRUE in Rh incompatibility? A. 100 cc. Serum magnesium level is 10mEg/L. 50. Which of the following conditions will lead to a small-for-gestational age fetus due to less blood supply to the fetus? A. the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. even if terminated into an abortion. On the first pregnancy of the Rh(-) mother. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis C. the nurse should assess the patient’s condition. Maternal cardiac condition C. Knee jerk reflex is (+)2 C. Premature labor D. Respiratory rate of 16/min Answer: (A) 100 cc. 51. 49.C. which can be dangerous to the mother. Abruptio placenta Answer: (B) Maternal cardiac condition In general. Endometriosis is a condition that is caused by organic abnormalities. RhoGam is given only during the first pregnancy to prevent incompatibility Answer: (C) On the first pregnancy of the Rh(-) mother. urine output in 4 hours The minimum urine output expected for a repeat dose of MgSO4 is 30 cc/hr. D. 52. Before giving a repeat dose of magnesium sulfate to a pre-eclamptic patient. If in 4 hours the urine output is only 100 cc this is low and can lead to poor excretion of Magnesium with a possible cumulative effect. Thus if the blood supply is less. Which of the following conditions will require the nurse to temporarily suspend a repeat dose of magnesium sulfate? A. Impotence Answer: (A) Vaginismus Vaginismus is primarily psychological in origin. there is already the possibility of mixing of maternal and fetal blood so this can trigger the maternal blood to produce antibodies against Rh(+) blood. Diabetes in the mother B. endometriosis or hormonal changes in menopause although may sometimes be psychological in origin. After the first pregnancy. The lower limit of viability for infants in terms of age of gestation is: .

Pushing requires more effort which a compromised heart may not be able to endure. Article XIII section 11 D. Article II section 15 C. Article XIII section 15 Answer: (A) Article II section 12 The Philippine Constitution of 1987 guarantees the right of the unborn child from conception equal to the mother as stated in Article II State Policies. The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesia. Abortion is illegal because majority in our country are catholics and it is prohibited by the church Answer: (B) Abortion is both immoral and illegal in our country Induced Abortion is illegal in the country as stated in our Penal Code and any person who performs the act for a fee commits a grave offense punishable by 1012 years of imprisonment. 56. The progress of labor is well established reaching the transitional stage B. Abortion is immoral and is prohibited by the church B. Section 12. 38-40 weeks Answer: (A) 21-24 weeks Viability means the capability of the fetus to live/survive outside of the uterine environment. Cervical dilatation has already reached at least 8 cm. To allow atraumatic delivery of the baby B. 21 weeks AOG is considered as the minimum fetal age for viability. Abortion is both immoral and illegal in our country C.A. The main rationale for this is: A. if a nurse performs abortion on the mother who wants it done and she gets paid for doing it. Which provision of our 1987 constitution guarantees the right of the unborn child to life from conception is A. 21-24 weeks B. When giving narcotic analgesics to mother in labor. Article II section 12 B. 53. To prevent perineal laceration with the expulsion of the fetal head Answer: (C) To make the delivery effort free and the mother does not need to push with contractions Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. With the present technological and medical advances. To make the delivery effort free and the mother does not need to push with contractions D. In the Philippines. the special consideration to follow is: A. To allow a gradual shifting of the blood into the maternal circulation C. 28-30 weeks D. she will be held liable because A. and the station is at least . Abortion is considered illegal because you got paid for doing it D. 54. 25-27 weeks C. Uterine contraction is progressing well and delivery of the baby is imminent C.

The duration of labor is normal Answer: (C) The active phase of Stage 1 is protracted The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour. 59. showed that cervical dilation was 7 cm.(+)2 D. 58. Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Which of the following techniques during labor and delivery can lead to uterine inversion? A.E. Hence.M. 57. If the cord goes out of the cervical opening. A repeat I. Determine if cord compression followed the rupture C. the cord may also go with the water because of the pressure of the rupture and flow. it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier. Since the time lapsed is already 2 hours. Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. Also. the active phase is protracted. The correct interpretation of this result is: A. Check if the fetus is suffering from head compression B. The cervical dilatation taken at 8:00 A. before the head is delivered (cephalic presentation).M. in a G1P0 patient was 6 cm. Massaging the fundus to encourage the uterus to contract D. Labor is progressing as expected B. Determine if there is utero-placental insufficiency D. Check if fetal presenting part has adequately descended following the rupture Answer: (B) Determine if cord compression followed the rupture After the rupture of the bag of waters. Fundal pressure applied to assist the mother in bearing down during delivery of the fetal head B. tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. The fetal heart rate is checked following rupture of the bag of waters in order to: A. the dilatation is expected to be already 8 cm. Applying light traction when delivering the placenta that has already detached from the uterine wall Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation When the placenta is still attached to the uterine wall. The latent phase of Stage 1 is prolonged C. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached. Answer: (D) Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. The active phase of Stage 1 is protracted D. the head . done at 10 A. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation C.

2. The following are signs and symptoms of fetal distress EXCEPT: A. 60. Likewise the maternal passageway (cervix. 1 & 2 B. FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm D. Inadequate tissue perfusion related to hemorrhage D. The FHR is less than 120 bpm or over 160 bpm C.3. the cause of the hemorrhage could be uterine atony. If the fundus is soft and boundaries not well defined. FHR is 160 bpm.can compress on the cord causing fetal distress.4 all the above conditions can occur following a precipitate labor and delivery of the fetus because there was little time for the baby to adapt to the passageway. vaginal canal and perineum) did not have enough time to stretch which can lead to laceration. During a contraction. it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. Thus. and possible compression of cord may occur which can lead to less blood and oxygen to the fetus (hypoxia). FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm The normal range of FHR is 120-160 bpm. the fetal head serves as the main part of the fetus that pushes through the birth canal which can lead to cranial hematoma.2. Hemorrhage secondary to uterine atony Answer: (D) Hemorrhage secondary to uterine atony All the signs in the stem of the question are signs of hemorrhage. Upon assessment. weak and irregular Answer: (C) The pre-contraction FHR is 130 bpm.Laceration of cervix 2.3. the nurse should suspect that the following conditions may occur: 1. strong and regular. Fetal distress can be detected through the fetal heart tone. the FHR usually goes down but must return to its pre-contraction rate after the contraction ends. fundus soft and boundaries not well defined. Normal blood loss B.Laceration of perineum 3. The pre-contraction FHR is 130 bpm. Blood volume deficiency C. 1.2.Cranial hematoma in the fetus 4. 63.3. PR= 80 bpm. The appropriate nursing diagnosis is: A.4 D. 61. the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours post partum. If the presentation is cephalic. The primary power involved in labor and delivery is . If the labor period lasts only for 3 hours.4 Answer: (D) 1. 62.Fetal anoxia A. 2 & 4 C. Fetal heart rate (FHR) decreased during a contraction and persists even after the uterine contraction ends B.

the right technique is to time the contraction A. From the end of one contraction to the beginning of the next contraction D. The end of one contraction to the beginning of another contraction C. When determining the duration of a uterine contraction the right technique is to time it from A. Valsalva technique Answer: (C) Uterine contraction Uterine contraction is the primary force that will expel the fetus out through the birth canal Maternal bearing down is considered the secondary power/force that will help push the fetus out. Acme C. Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction D. From the beginning of one contraction to the beginning of the next contraction C. Axiom Answer: (B) Acme Acme is the technical term for the highest point of intensity of a uterine contraction. To monitor the frequency of the uterine contraction during labor. The beginning of one contraction to the end of another contraction . Uterine contraction D. The proper technique to monitor the intensity of a uterine contraction is A. Put the palm of the hands on the fundal area and feel the contraction at the fundal area Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction In monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. The beginning of one contraction to the end of the same contraction B. From the deceleration of one contraction to the acme of the next contraction Answer: (B) From the beginning of one contraction to the beginning of the next contraction Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction.A. 66. Place the finger tips lightly on the suprapubic area and time the contraction C. 65. The fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand. Acceleration B. Deceleration D. 64. From the beginning of one contraction to the end of the same contraction B. Cervical effacement and dilatation C. Bearing down ability of mother B. The acme point of one contraction to the acme point of another contraction D. The peak point of a uterine contraction is called the A. Place the palm of the hands on the abdomen and time the contraction B. 67.

Push back the cord into the vagina and place the woman on sims position Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. 69. Bluish C. extension. Clear as water B. there is probably Rh incompatibility. flexion. Observe strict asepsis in the care of the cord to prevent infection. D. When the bag of waters ruptures spontaneously. The mechanisms involved in fetal delivery is A. Yellowish Answer: (A) Clear as water The normal color of amniotic fluid is clear like water. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on trendellenberg or sims position 70. The normal color of amniotic fluid is A. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is: A. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position D. When the bag of waters ruptures. Push back the prolapse cord into the vaginal canal B. The fetal heart beat should be monitored every 15 minutes during the 2nd stage of labor. The rate should not be affected by the uterine contraction. 68. The heart rate will decelerate during a contraction and then go back to its precontraction rate after the contraction B. The heart rate will decelerate at the middle of a contraction and remain so for about a minute after the contraction Answer: (A) The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction The normal fetal heart rate will decelerate (go down) slightly during a contraction because of the compression on the fetal head. the nurse should check the characteristic of the amniotic fluid. the heart rate should go back to the pre-contraction rate as soon as the contraction is over since the compression on the head has also ended. Greenish D. The heart rate will accelerate during a contraction and remain slightly above the pre-contraction rate at the end of the contraction C. external rotation . it is probably meconium stained. Place the mother on semifowler’s position to improve circulation C. However. If it is yellowish. The cord has to be kept moist to prevent it from drying. 71. If the color is greenish. The characteristic of a normal fetal heart rate is A.Answer: (A) The beginning of one contraction to the end of the same contraction Duration of a uterine contraction refers to one contraction. Descent. the nurse should inspect the vaginal introitus for possible cord prolapse.

extension. flexion. if mucus is in the nose and mouth. external rotation.) 74. The cord is intact B. extension.Check if the placenta is complete including the membranes . 72. Suction the nose and mouth to remove mucous secretions B. Flexion. Check the baby’s color to make sure it is not cyanotic Answer: (A) Suction the nose and mouth to remove mucous secretions Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. The cord is still pulsating Answer: (B) No part of the cord is encircling the baby’s neck The nurse should check right away for possible cord coil around the neck because if it is present. The cord is still attached to the placenta D. external rotation C. Descent. To ensure that the baby will breath as soon as the head is delivered. Clamp the cord about 6 inches from the base D. external rotation. Clean from the mons veneris to the anus C. 73. Use mild soap and warm water D. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus. The perineal area is the one being prepared for the delivery and must be kept clean 75. Paint the inner thighs going towards the perineal area Answer: (D) Paint the inner thighs going towards the perineal area Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. extension D. extension. external rotation The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. internal rotation. What are the important considerations that the nurse must remember after the placenta is delivered? 1. flexion Answer: (B) Descent. aspiration of the mucus is possible which can lead to aspiration pneumonia. the nurse’s priority action is to A. Flexion. the baby can be strangulated by it and the fetal head will have difficulty being delivered. the nurse should observe the following EXCEPT A. When doing perineal care in preparation for delivery. internal rotation and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal. No part of the cord is encircling the baby’s neck C. Use up-down technique with one stroke B. (Remember that only the baby’s head has come out as given in the situation. flexion.B. Slap the baby’s buttocks to make the baby cry C. internal rotation. Also. The first thing that a nurse must ensure when the baby’s head comes out is A. internal rotation. Internal rotation.

Also. The following are correct statements about false labor EXCEPT A. 78.Check if the cord is long enough for the baby 3. the contractions remain to be irregular in intensity and duration while in true labor.Check if the cord has a meaty portion and a shiny portion A. longer and more frequent. The duration of contraction progressively lengthens over time C. 2 and 3 Answer: (A) 1 and 3 The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete. 79. 2 veins and 1 artery. 2 arteries and 2 veins D. At what stage of labor and delivery does a primigravida differ mainly from a multigravida? A. 1 and 3 B. Distensibility of lower uterine segment B. 3. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus. B. 2 arteries and 1 vein B. There is no vaginal bloody discharge D. The normal umbilical cord is composed of: A. The pain is irregular in intensity and frequency. The cervix is still closed. The passageway in labor and deliver of the fetus include the following EXCEPT A. Stage 4 . 76. 77. none of the above Answer: (A) 2 arteries and 1 vein the umbilical cord is composed of 2 arteries and 1 vein. Stage 1 B. Stage 2 C. 1. 2 veins and 1 artery C. Stage 3 D. the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels.Check if the umbilical cord has 3 blood vessels 4.2. Cervical dilatation and effacement C. Distensibility of vaginal canal and introitus D. and 4 D. Answer: (B) The duration of contraction progressively lengthens over time In false labor. Flexibility of the pelvis Answer: (D) Flexibility of the pelvis The pelvis is a bony structure that is part of the passageway but is not flexible. 2 and 4 C. the contractions become stronger.

Answer: (A) Stage 1 In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor. 80. The second stage of labor begins with ___ and ends with __? A. Begins with full dilatation of cervix and ends with delivery of placenta B. Begins with true labor pains and ends with delivery of baby C. Begins with complete dilatation and effacement of cervix and ends with delivery of baby D. Begins with passage of show and ends with full dilatation and effacement of cervix Answer: (C) Begins with complete dilatation and effacement of cervix and ends with delivery of baby Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of baby. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix. 81. The following are signs that the placenta has detached EXCEPT: A. Lengthening of the cord B. Uterus becomes more globular C. Sudden gush of blood D. Mother feels like bearing down Answer: (D) Mother feels like bearing down Placental detachment does not require the mother to bear down. A normal placenta will detach by itself without any effort from the mother. 82. When the shiny portion of the placenta comes out first, this is called the ___ mechanism. A. Schultze B. Ritgens C. Duncan D. Marmets Answer: (A) Schultze There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes out first, it is called the Schultze mechanism; while if the meaty portion comes out first, it is called the Duncan mechanism. 83. When the baby’s head is out, the immediate action of the nurse is A. Cut the umbilical cord B. Wipe the baby’s face and suction mouth first C. Check if there is cord coiled around the neck D. Deliver the anterior shoulder Answer: (C) Check if there is cord coiled around the neck The nurse should check if there is a cord coil because the baby will not be delivered safely if the cord is coiled around its neck. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a “nasal obligate” breather. If the nose is suctioned first before the mouth, the mucus plugging the

mouth can be aspirated by the baby. 84. When delivering the baby’s head the nurse supports the mother’s perineum to prevent tear. This technique is called A. Marmet’s technique B. Ritgen’s technique C. Duncan maneuver D. Schultze maneuver Answer: (B) Ritgen’s technique Ritgen’s technique is done to prevent perineal tear. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby’s head as it goes out of the vaginal opening. 85. The basic delivery set for normal vaginal delivery includes the following instruments/articles EXCEPT: A. 2 clamps B. Pair of scissors C. Kidney basin D. Retractor Answer: (D) Retractor For normal vaginal delivery, the nurse needs only the instruments for cutting the umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the kidney basin to receive the placenta. The retractor is not part of the basic set. In the hospital setting, needle holder and tissue forceps are added especially if the woman delivering the baby is a primigravida wherein episiotomy is generally done. 86. As soon as the placenta is delivered, the nurse must do which of the following actions? A. Inspect the placenta for completeness including the membranes B. Place the placenta in a receptacle for disposal C. Label the placenta properly D. Leave the placenta in the kidney basin for the nursing aide to dispose properly Answer: (A) Inspect the placenta for completeness including the membranes The placenta must be inspected for completeness to include the membranes because an incomplete placenta could mean that there is retention of placental fragments which can lead to uterine atony. If the uterus does not contract adequately, hemorrhage can occur. 87. In vaginal delivery done in the hospital setting, the doctor routinely orders an oxytocin to be given to the mother parenterally. The oxytocin is usually given after the placenta has been delivered and not before because: A. Oxytocin will prevent bleeding B. Oxytocin can make the cervix close and thus trap the placenta inside C. Oxytocin will facilitate placental delivery D. Giving oxytocin will ensure complete delivery of the placenta Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside

The action of oxytocin is to make the uterus contract as well make the cervix close. If it is given prior to placental delivery, the placenta will be trapped inside because the action of the drug is almost immediate if given parentally. 88. In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and delivery) particularly in a cesarean section is a critical period because at this stage A. There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. B. The maternal heart is already weak and the mother can die C. The delivery process is strenuous to the mother D. The mother is tired and weak which can distress the heart Answer: (A) There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. During the pregnancy, there is an increase in maternal blood volume to accommodate the need of the fetus. When the baby and placenta have been delivered, there is a fluid shift back to the maternal circulation as part of physiologic adaptation during the postpartum period. In cesarean section, the fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving it less time for the fluid shift to gradually occur. 89. The drug usually given parentally to enhance uterine contraction is: A. Terbutalline B. Pitocin C. Magnesium sulfate D. Lidocaine Answer: (B) Pitocin The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug given to induce labor. 90. The partograph is a tool used to monitor labor. The maternal parameters measured/monitored are the following EXCEPT: A. Vital signs B. Fluid intake and output C. Uterine contraction D. Cervical dilatation Answer: (B) Fluid intake and output Partograph is a monitoring tool designed by the World Health Organization for use by health workers when attending to mothers in labor especially the high risk ones. For maternal parameters all of the above is placed in the partograph except the fluid intake since this is placed in a separate monitoring sheet. 91. The following are natural childbirth procedures EXCEPT: A. Lamaze method B. Dick-Read method C. Ritgen’s maneuver D. Psychoprophylactic method Answer: (C) Ritgen’s maneuver Ritgen’s method is used to prevent perineal tear/laceration during the delivery of

the station is “0”. 1. Station +2 Answer: (B) Station “0” Station is defined as the relationship of the fetal head and the level of the ischial spine./hr For nullipara the normal cervical dilatation should be 1.2 cm.2 cm. Extension rather than flexion of the head D. Above the ischial spine it is considered (-) station and below the ischial spine it is (+) station. Station +1 D. 2. Station –1 B./hr./hr Answer: (A) 1.5 cm./hr B. If it is less than that. it is said that the station of the head is A. Which of these can a nurse. This should be augmented by the mother’s bearing down during a contraction. it is considered a protracted active phase of the first stage. 95. At what stage of labor is the mother is advised to bear down? A. 1.2 cm/hr. C. the nurse palpated the posterior fontanel to be at the left side of the mother at the upper quadrant. During a uterine contraction C. For multipara. The normal dilatation of the cervix during the first stage of labor in a nullipara is A. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain. When the mother feels the pressure at the rectal area B. LOA B.8 cm. In between uterine contraction to prevent uterine rupture D.the fetal head. When the fetal head is at the level of the ischial spine. Full bladder C.5 cm/hr. Pelvic bone contraction B. the normal cervical dilatation is 1. Anytime the mother feels like bearing down Answer: (B) During a uterine contraction The primary power of labor and delivery is the uterine contraction. At the level of the ischial spine. The nurse can readily manage this problem by doing a simple catheterization of the mother. 93. 94.0 cm. Station “0” C. 1. Cervical rigidity Answer: (B) Full bladder Full bladder can impede the descent of the fetal head./hr D. 96. The following are common causes of dysfunctional labor. The interpretation is that the position of the fetus is: A. 92. ROP . on her own manage? A. During an internal examination.

probably the placenta is abnormally adherent and there is a need to refer already to the obstetrician. The umbilicus to the mid-thigh C. 5 minutes B. it is frank breech. If both the feet and the buttocks are presenting it is called complete breech. the right term for this observation that the fetus is A. Complete D. 30 minutes C. 98. Incomplete Answer: (D) Incomplete Breech presentation means the buttocks of the fetus is the presenting part. Xyphoid process to the pubic area D. Floating D. LOP D. Engaged B. 45 minutes D. When shaving a woman in preparation for cesarean section. 99. If it takes longer. The pubic hair is . If only the buttocks.C. Under breast to mid-thigh including the pubic area B. Footling B. The following are types of breech presentation EXCEPT: A. 97. Internal Rotation Answer: (C) Floating The term floating means the fetal presenting part has not entered/descended into the pelvic inlet. 100. So if the nurse palpated the occiput (O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal position is LOA. cesarean section. 60 minutes Answer: (B) 30 minutes The placenta is delivered within 30 minutes from the delivery of the baby. Descended C. the area to be shaved should be from ___ to ___ A. ROA Answer: (A) LOA The landmark used in determine fetal position is the posterior fontanel because this is the nearest to the occiput. A. Above the umbilicus to the pubic area Answer: (A) Under breast to mid-thigh including the pubic area Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery. If it is only the foot/feet. Frank C. The placenta should be delivered normally within ___ minutes after the delivery of the baby. it is said to be engaged. If the fetal head has entered the pelvic inlet. When the nurse palpates the suprapubic area of the mother and found that the presenting part is still movable. it is considered footling.

Prevent the recurrence of Rh(+) baby in future pregnancies B. The lochia on the first few days after delivery is characterized as A. 7-10 days C.0 cm Answer: (A) 1. lochia disappears after 10 days postpartum. Since it is not pure blood it is non-clotting. Reddish with some mucus D.definitely to be included in the shaving 101.5 cm D. 2. Serous with some brown tinged mucus Answer: (C) Reddish with some mucus Right after delivery. 1. 102. To prevent the newborn from having problems of incompatibility when it breastfeeds Answer: (B) Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby In Rh incompatibility. After an Rh(-) mother has delivered her Rh (+) baby. endometrial tissue and mucus. Whitish with some mucus C. Lochia normally disappears after how many days postpartum? A. Ensure that future pregnancies will not lead to maternal illness D. A.0 cm The uterus will begin involution right after delivery.0 cm C. 3. 103. 104. 5 days B. the mother is given RhoGam. the vaginal discharge called lochia will be reddish because there is some blood. an Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. 2. It is expected to regress/go down by 1 cm. Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby C. Giving her RhoGam right after birth will . Pinkish with some blood clots B. This is done in order to: A. 18-21 days D. per day and becomes no longer palpable about 1 week after delivery.0 cm B. Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day. 28-30 days Answer: (B) 7-10 days Normally. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday.

Apply analgesic ointment Answer: (B) Apply warm compress on the engorged breast Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. However. the compress applied is cold. To ensure adequate lactation the nurse should teach the mother to: A. 12-24 hours Answer: (C) 6-8 hrs A woman who has had normal delivery is expected to void within 6-8 hrs. 3 hrs B. Apply cold compress on the engorged breast B. If she is unable to do so after 8 hours. aerobics does not necessarily enhance lactation. 105. Feed the baby every 3-4 hours following a strict schedule D. Increase fluid intake including milk B. 109. Elevate the affected leg and keep the patient on bedrest . A. the nurse should stimulate the woman to void. 6-8 hrs D. Massage the breast D. this means there will be regular emptying of the breasts. 106. A woman who delivered normally per vagina is expected to void within ___ hours after delivery. 4 hrs. If nursing interventions to stimulate spontaneous voiding don’t work. Feed primarily during the day and allow the baby to sleep through the night C. Apply warm compress on the affected leg to relieve the pain D. Breast feed the baby on self-demand day and night B. 107. If the purpose is to relieve pain as well as suppress lactation. The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is A. C. Exercise adequately like aerobics D. 108. Apply warm compress on the engorged breast C.prevent her immune system from being permanently sensitized to Rh antigen. Have adequate nutrition and rest Answer: (C) Exercise adequately like aerobics All the above nursing measures are needed to ensure that the mother is in a healthy state. Eat foods that increases lactation which are called galactagues C. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is: A. Instruct the mother to apply elastic bondage from the foot going towards the knee to improve venous return flow C. Encourage the mother to ambulate to relieve the pain in the leg B. the nurse may decide to catheterize the woman. To enhance milk production. Therefore. which is essential to maintain adequate lactation. Breastfeed when the breast are engorged to ensure adequate supply Answer: (A) Breast feed the baby on self-demand day and night Feeding on self-demand means the mother feeds the baby according to baby’s need. a lactating mother must do the following interventions EXCEPT: A.

Going through. letting-go. adjustment phase. His kidneys are immature leading to a high tolerance for glucose Answer: (B) There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin If the mother is diabetic. There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin C. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus. Placental delivery occurred within thirty minutes after the baby was born C. BP diastolic increase from 80 to 95mm Hg C. adjustment period. the neonate usually does not feed yet thus this can lead to hypoglycemia. Respiratory rate of 16-20/min . the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation. Which of the following is an abnormal vital sign in postpartum? A. An episiotomy had to be done to facilitate delivery of the head D. The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally if this condition was present during the delivery: A. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because: A. In the first few hours after delivery. Attachment phase. taking-hold and letting-go. it no longer receives a high dose of glucose from the mother. The labor and delivery lasted for 12 hours Answer: (A) Excessive analgesia was given to the mother Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally.Answer: (D) Elevate the affected leg and keep the patient on bedrest If the mother already has thrombophlebitis. adaptation period B. taking-hold and letting-go Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in. Taking-hold. In taking-hold. BP systolic between 100-120mm Hg D. 113. the mother is more passive and dependent on others for care. When the baby is born and is now separate from the mother. 110. 112. attachment phase Answer: (B) Taking-in. These stages are: A. In the taking-in stage. the fetus while in utero has a high supply of glucose. 111. According to Rubin’s theory of maternal role adaptation. The pancreas is immature and unable to secrete the needed insulin B. adaptation phase D. The baby is reacting to the insulin given to the mother D. the mother will go through 3 stages during the post partum period. the mother has become adapted to her maternal role. taking-hold and letting-go C. the mother begins to assume a more active role in the care of the child and in lettinggo. Excessive analgesia was given to the mother B. Taking-in. Pulse rate between 50-60/min B.

the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Folicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a graafian follicle and the menstrual cycle post pregnancy resumes. The uterine fundus right after delivery of placenta is palpable at A.Answer: (B) BP diastolic increase from 80 to 95mm Hg All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy. 12 months Answer: (B) 6-8 weeks When the mother does not breastfeed. 6 weeks D. Breast massage D. 6 months D. Application of cold compress on the breast Answer: (D) Application of cold compress on the breast To stimulate lactation. 12 weeks Answer: (C) 6 weeks According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to make sure complete involution of the reproductive organs has be achieved. Level of umbilicus C. Frequent regular breast feeding B. 2 weeks B. Breast pumping C. 115. menstruation usually occurs after how many weeks? A. This is due to the fact that after delivery. Cold application will cause vasoconstriction thus reducing the blood supply consequently the . Level of symphysis pubis D. In a woman who is not breastfeeding. 114. 6-8 weeks C. Midway between umbilicus and symphysis pubis Answer: (B) Level of umbilicus Immediately after the delivery of the placenta. The following are nursing measures to stimulate lactation EXCEPT A. the normal menstruation resumes about 6-8 weeks after delivery. Level of Xyphoid process B. 116. 3 weeks C. warm compress is applied on the breast. 2-4 weeks B. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it becomes no longer palpable above the symphysis pubis. After how many weeks after delivery should a woman have her postpartal check-up based on the protocol followed by the DOH? A. 117.

The following are nursing interventions to relieve episiotomy wound pain EXCEPT A. Sitz bath C. Massage the fundus vigorously for 15 minutes until contracted D. poor appetite. If massaging is vigorous and prolonged. 120. the uterus will relax due to over stimulation. Woman exhibits the following symptoms. Maybe more severe symptoms in primpara A. 1 and 2 C. Uterine inversion D. Make the baby suck the breast regularly B. fatigue. Postpartum blues is said to be normal provided that the following characteristics are present.production of milk. 121. Perineal care Answer: (D) Perineal care Perineal care is primarily done for personal hygiene regardless of whether there is pain or not. 119. episiotomy wound or not. These are 1. All of the above B. Uterine hypercontractility Answer: (A) Laceration of soft tissues of the cervix and vagina When uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina. Give oxytocin as ordered Answer: (C) Massage the fundus vigorously for 15 minutes until contracted Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feel firm and contracted. The following are interventions to make the fundus contract postpartally EXCEPT A.episodic tearfulness. 3. Within 3-10 days only. the nurse should suspect A. It will resolve by itself because it is transient and is due to a number of reasons like changes in hormonal levels and adjustment to motherhood. Laceration of soft tissues of the cervix and vagina B. Giving analgesic as ordered B. 118. 2. 2 and 3 Answer: (A) All of the above All the symptoms 1-3 are characteristic of postpartal blues. 2 only D. Apply ice cap on fundus C. Uterine atony C. When the uterus is firm and contracted after deli very but there is vaginal bleeding. oversensitivity. If symptoms lasts more than 2 . Perineal heat D.

this could be a sign of abnormality like postpartum depression and needs treatment. abdominal breathing D. Right upper arm B. 123. 30-50 breaths per minute. The blood in left side of the fetal heart contains oxygenated blood while the blood in the right side contains unoxygenated blood. active use of abdominal and intercostal muscles Answer: (A) Shallow and irregular with short periods of apnea lasting not longer than 15 seconds. The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. 124. The fetal lungs is fluid-filled while in utero and is still not functioning. abdominal breathing with active use of intercostals muscles C. None of the above Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds. Except for the blood as it enters the fetus immediately from the placenta. 20-40 breaths per minute. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea. 122. 30-60 breaths per minute A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to function as a respiratory organ. most of the fetal blood is mixed blood. The posterior fontanelle is triangular shape. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal.weeks. 30-60 breaths per minute. 30-60 breaths per minute with apnea lasting more than 15 seconds. 30-60 breaths per minute B. 2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape C. It only begins to function in extra uterine life. diamond shape B. The ideal site for vitamin K injection in the newborn is: A. B. D. diamond shape The anterior fontanelle is diamond shape with the antero-posterior diameter being longer than the transverse diameter. The blood at the left atrium of the fetal heart is shunted to the right atrium to facilitate its passage to the lungs C. 2-3 cm in both antero-posterior and transverse diameter and diamond shape D. The normal respiration of a newborn immediately after birth is characterized as: A. The anterior fontanelle is characterized as: A. 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter. The neonatal circulation differs from the fetal circulation because A. 125. none of the above Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter. Left upper arm .

126. 9-10 D. 127. 129. Middle third of the thigh Answer: (D) Middle third of the thigh Neonates do not have well developed muscles of the arm. 6-7 Answer: (A) 1-3 An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. 1-3 B.000gms Answer: (C) 2. At what APGAR score at 5 minutes after birth should resuscitation be initiated? A. 7-8 C. when the skin of the baby’s trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called: A.500gms According to the WHO standard. The minimum birth weight for full term babies to be considered normal is: A.500gms D. 3. Syndactyly B. 2. 128.C. Right after birth.000gms B. Peripheral cyanosis D.500gms C. the minimum normal birth weight of a full term baby is 2. Since Vitamin K is given intramuscular. the site must have sufficient muscles like the middle third of the thigh. Cephalo-caudal cyanosis Answer: (B) Acrocyanosis Acrocyanosis is the term used to describe the baby’s skin color at birth when the soles and palms are bluish but the trunk is pinkish. 2.5 Kg. The baby is alright if the score is 8-10. Ritgen’s method D. an ophthalmic ointment is used. 130. 1. The procedure done to prevent ophthalmia neonatorum is: A.500 gms or 2. Crede’s method C. Marmet’s technique B. Ophthalmic wash Answer: (B) Crede’s method Crede’s method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acquire as it passes through the birth canal of the mother. Usually. Which of the following characteristics will distinguish a postmature neonate . Acrocyanosis C. Either right or left buttocks D.

3 and 4 D. cracked skin.4 degrees centigrade B. A.2-0.4 degrees centigrade 133. 1. and 4 Answer: (B) 1.at birth? A. the sign that ovulation has occurred is an elevation of body temperature by A. 3. there is no longer an explicit provision stating that the nurse still needs special training for IV insertion.2 – 0. 2. 1. 2. The mother uses mixed feeding faithfully D. Lanugo mainly on the shoulders and vernix in the skin folds C. The mother breast feeds mainly at night time when ovulation could possibly occur B. Pinkish skin with good turgor D. Also. a registered nurse is allowed to handle mothers in labor and delivery with the following considerations: 1.0-4. 2. As a delivery room nurse she is not allowed to insert intravenous fluid unless she had special training for it. and 3 To be allowed to handle deliveries.4 degrees centigrade C. negligible vernix caseosa Answer: (D) Almost leather-like.0 degrees centigrade D. negligible vernix caseosa A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished.2-0. Birth Control Methods and Infertility: In basal body temperature (BBT) technique. The pregnancy is normal. 131. 132. Almost leather-like. 0. Plenty of lanugo and vernix caseosa B. 1.0-4.4 degrees centigrade The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body temperature of about 0. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if A. The mother breastfeeds regularly until 1 year with no supplemental feedings Answer: (B) The mother breastfeeds exclusively and regularly during the first 6 . and 3 C. And in RA9172. 2. dry. the pregnancy must be normal and uncomplicated. The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings C. cracked skin.. the nurse is now allowed to suture perineal lacerations provided s/he has had the special training.0 degrees centigrade Answer: (B) 0. 1 and 2 B.0-1. The labor and delivery is uncomplicated. Suturing of perineal laceration is allowed provided the nurse had special training. 2. in this law. dry. 4. 1. According to the Philippine Nursing Law.

Mittelschmerz. A. The natural family planning method called Standard Days (SDM).0 degrees centigrade 1&2 . Fundus contracts to expel uterine contents C.months without giving supplemental feedings A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhea. Sperms will be barred from entering the fallopian tubes Answer: (D) Sperms will be barred from entering the fallopian tubes An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the initial reaction is to produce inflammatory process and the uterus will contract in order to try to expel the foreign body. Elevated body temperature of 4. Oral contraceptive pills are of different types. 3. 24. 137. However. 135. Thin watery cervical mucus. Spinnabarkeit. There is no need to monitor temperature or mucus secretion. is the latest type and easy to use method. Estrogen only B. Copper embedded in the IUD can kill the sperms D.estrogen and progesterone D. 134. But the IUD does not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through. This natural method of family planning is very simple since all that the woman pays attention to is her cycle.36 days Answer: (B) 26-32 days Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days. 21-26 days B. 4. Progesterone only C. the woman can easily monitor her cycles. 28-30 days D. A. Usually IUDs are coated with copper to serve as spermicide killing the sperms deposited into the female reproductive tract. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT A. Which type is most appropriate for mothers who are breastfeeding? A. Which of the following are signs of ovulation? 1. With the aid of CycleBeads. 136. 2. There is evidence to support the observation that the benefits of lactation amenorrhea lasts for 6 months provided the woman has not had her first menstruation since delivery of the baby. 26-32 days C. 21-day pills mixed type Answer: (B) Progesterone only If mother is breastfeeding. Mixed type. Endometrium inflames B. it is a method applicable only to women with regular menstrual cycles between ___ to ___ days. the progesterone only type is the best because estrogen can affect lactation.

4 Answer: (C) 1. Undergo a complete medical check-up to rule out any debilitating disease A.3. Cervical cap C. Every menstrual period is always preceded by ovulation D. the following means can be done: 1. 1. 1 only B. If a couple would like to enhance their fertility. 3.2. Some IUDs have copper added to it which is spermicidal. 1. 3 & 4 D. 2. spinnabarkeit and thin watery cervical mucus are signs of ovulation. there will be no ovulation.2-0. the hormone progesterone is released which can cause a slight elevation of temperature between 0. 2. It is not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube. The most fertile period of a woman is 2 days after ovulation Answer: (B) It may occur between 14-16 days before next menstruation Not all menstrual cycles are ovulatory.2.4 degrees centigrade and not 4 degrees centigrade.B. 3 because during the dry period the woman is in her infertile period thus even when sexual contact is done. Have adequate rest and nutrition. When ovulation occurs. 4. 1. & 3 C. It may occur between 14-16 days before next menstruation C. 4 Answer: (B) 1. thus fertilization is not possible. & 3 Mittelschmerz. 1 & 4 C. 3. This is a misconception because ovulation is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next menstruation. The following methods of artificial birth control works as a barrier device EXCEPT: A. Normal ovulation in a woman occurs between the 14th to the 16th day before the NEXT menstruation. 139. 1. Have sexual contact only during the dry period of the woman.4 All of the above are essential for enhanced fertility except no.2. A common misconception is that ovulation occurs on the 14th day of the cycle. Cervical Diaphragm D. Which of the following is a TRUE statement about normal ovulation? A. Monitor the basal body temperature of the woman everyday to determine peak period of fertility. 2. 140. 138. It occurs on the 14th day of every cycle B.4 D. Intrauterine device (IUD) Answer: (D) Intrauterine device (IUD) Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium. 2. Condom B. .

softness of the cervix and cervical mucus that looks like the white of an egg which makes the woman feel “wet”. she needs to take another temporary method until she has consumed the whole pack D. The normal sperm count is 20 million per milliliter of seminal fluid or 50 . 144. To determine if the cause of infertility is a blockage of the fallopian tubes. temperature and vagina C. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. Huhner’s test is also known as post-coital test to determine compatibility of the cervical mucus with sperms of the sexual partner. mucus Answer: (A) Temperature. If the woman fails to take a pill in one day. she can already discontinue using the second temporary method she employed. None of the above Answer: (B) Rubin’s test Rubin’s test is a test to determine patency of fallopian tubes. Orchitis C. The pill must be taken everyday at the same time B. Infertility can be attributed to male causes such as the following EXCEPT: A. the test to be done is A. Cryptorchidism B. If she is breast feeding. she must take 2 pills for added protection If the woman fails to take her usual pill for the day. Premature ejaculation Answer: (C) Sperm count of about 20 million per milliliter Sperm count must be within normal in order for a male to successfully sire a child. Huhner’s test B. cervical mucus. cervical consistency B. Temperature. Postcoital test D.temperature increase of about 0. In sympto-thermal method. Temperature and wetness D. If the woman fails to take a pill in one day. The following are important considerations to teach the woman who is on low dose (mini-pill) oral contraceptive EXCEPT: A. Rubin’s test C. the parameters being monitored to determine if the woman is fertile or infertile are: A. 143. endometrial secretion.4 degrees centigrade. she must take 2 pills for added protection C. cervical mucus. she should discontinue using mini-pill and use the progestin-only type Answer: (B) If the woman fails to take a pill in one day. taking a double dose does not give additional protection. Release of ovum. When a new pack is started. cervical consistency The 3 parameters measured/monitored which will indicate that the woman has ovulated are.141. 142. Sperm count of about 20 million per milliliter D.2-0. Temperature.

Thick mucus vaginal discharge influence by high level of estrogen Answer: (A) Thin watery mucus which can be stretched into a long strand about 10 cm At the midpoint of the cycle when the estrogen level is high. Thick mucus that is detached from the cervix during ovulation C. Just before the menstrual period to determine if ovulation has occurred Answer: (C) Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen The best time to do self breast examination is right after the menstrual period is over so that the hormonal level is low thus the breasts are not tender. Thin watery mucus which can be stretched into a long strand about 10 cm B. 145. And the woman feels “wet”. the cervical mucus becomes thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to fertilize an ovum. The organ involved in this procedure is A. 24 months Answer: (B) 12 months If a woman has not had her menstrual period for 12 consecutive months. Testes D. When progesterone is secreted by the ovary. A woman is considered to be menopause if she has experienced cessation of her menses for a period of A. 18 months D. Seminal vesicle C. 6 months B. 148. During the menstrual period C. Vasectomy is a procedure done on a male for sterilization.million per ejaculate. Prostate gland B. Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen D. Thin mucus that is yellowish in color with fishy odor D. Vas deferens Answer: (D) Vas deferens Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation. Breast self examination is best done by the woman on herself every month during A. 147. 146. she is considered to be in her menopausal stage. The middle of her cycle to ensure that she is ovulating B. Spinnabarkeit is an indicator of ovulation which is characterized as: A. This is called spinnabarkeit. . 12 months C. the mucus becomes thick and the woman will feel “dry”.

Which of the following is the correct practice of self breast examination in a menopausal woman? A. She should do it at the usual time that she experiences her menstrual period in the past to ensure that her hormones are not at its peak B. Bromocriptine B. Anytime she feels like doing it ideally every day D. Provera D. In assisted reproductive technology (ART). Clomiphene C. The drug commonly used for this purpose is: A. Menopausal women do not need regular self breast exam as long as they do it at least once every 6 months Answer: (B) Any day of the month as long it is regularly observed on the same day every month Menopausal women still need to do self examination of the breast regularly. The hormones estrogen and progesterone are already diminished during menopause so there is no need to consider the time to do it in relation to the menstrual cycle. The mature ova are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and after 48 hours the fertilized ovum is inserted into the uterus for implantation.149. there is a need to stimulate the ovaries to produce more than one mature ova. Any day of the month is alright provided that she practices it monthly on the same day that she has chosen. Any day of the month as long it is regularly observed on the same day every month C. 150. . Esrogen Answer: (B) Clomiphene Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation.

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