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  • 1. Nursing Board Practice Test Compilation FOUNDATION OF PROFESSIONAL NURSING PRACTICE 188 Contents NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE .......................................................................... 4 NURSING PRACTICE II ..................................................... 15 NURSING PRACTICE III .................................................... 26 NURSING PRACTICE IV.................................................... 36 NURSING PRACTICE V..................................................... 46 TEST I - Foundation of Professional Nursing Practice .... 56 Answers and Rationale – Foundation of Professional Nursing Practice ......................................................... 66 TEST II - Community Health Nursing and Care of the Mother and Child ........................................................... 74 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ............................. 84 ANSWER KEY - FOUNDATION OF PROFESSIONAL NURSING PRACTICE.................................................. 199 COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .................................................... 200 ANSWER KEY: COMMUNITY HEALTH NURSING AND CARE OF THE MOTHER AND CHILD .......................... 211 Comprehensive Exam 1................................................ 213 CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS...................................... 222 ANSWER KEY: CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS ......................... 234 Nursing Practice Test V ................................................ 235 Nursing Practice Test V ................................................ 245 TEST I - Foundation of Professional Nursing Practice .. 255 TEST III - Care of Clients with Physiologic and Psychosocial Alterations ................................................ 91 Answers and Rationale – Foundation of Professional Nursing Practice ....................................................... 265 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 102 TEST II - Community Health Nursing and Care of the Mother and Child ......................................................... 273 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 111 Answers and Rationale – Community Health Nursing and Care of the Mother and Child ........................... 283 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 122 TEST III - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 290 TEST V - Care of Clients with Physiologic and Psychosocial Alterations.................................................................... 133 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 301 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 144 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations .............................................. 310 PART III PRACTICE TEST I FOUNDATION OF NURSING . 153 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 321 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 158 PRACTICE TEST II Maternal and Child Health ............... 162 ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH..................................................................... 167 MEDICAL SURGICAL NURSING ..................................... 173 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 178 PSYCHIATRIC NURSING ................................................ 180 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 185 TEST V - Care of Clients with Physiologic and Psychosocial Alterations.................................................................... 332 Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations ................ 343 PART III ......................................................................... 352 PRACTICE TEST I FOUNDATION OF NURSING .............. 352 ANSWERS AND RATIONALE – FOUNDATION OF NURSING .................................................................. 357 PRACTICE TEST II Maternal and Child Health ............... 361
  • 2. ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH..................................................................... 366 MEDICAL SURGICAL NURSING ..................................... 372 MEDICAL SURGICAL NURSING Part 1 ........................... 475 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 1 ........................................................ 479 ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING .................................................................. 377 MEDICAL SURGICAL NURSING Part 2 ........................... 481 PSYCHIATRIC NURSING ................................................ 379 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 2 ........................................................ 489 ANSWERS AND RATIONALE – PSYCHIATRIC NURSING ................................................................................. 384 FUNDAMENTALS OF NURSING PART 1 ........................ 387 FUNDAMENTALS OF NURSING PART 2 ........................ 392 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 2 ...................................................... 397 FUNDAMENTALS OF NURSING PART 3 ........................ 401 ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PART 3 ...................................................... 405 MATERNITY NURSING Part 1 ........................................ 409 ANSWERS and RATIONALES for MATERNITY NURSING Part 1 ........................................................................ 418 MEDICAL SURGICAL NURSING Part 2 ....................... 485 MEDICAL SURGICAL NURSING Part 3 ........................... 491 ANSWERS and RATIONALES for MEDICAL SURGICAL NURSING Part 3 ........................................................ 495 PSYCHIATRIC NURSING Part 1 ...................................... 497 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 1 ........................................................................ 502 PSYCHIATRIC NURSING Part 2 ...................................... 504 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 2 ........................................................................ 509 PSYCHIATRIC NURSING Part 3 ...................................... 512 MATERNITY NURSING Part 2 ........................................ 428 ANSWERS and RATIONALES for PSYCHIATRIC NURSING Part 3 ........................................................................ 516 Answer for maternity part 2 .................................... 433 PROFESSIONAL ADJUSTMENT ...................................... 519 PEDIATRIC NURSING .................................................... 434 LEADERSHIP and MANAGEMENT ................................. 522 ANSWERS and RATIONALES for PEDIATRIC NURSING ................................................................................. 439 NURSING RESEARCH Part 1 .......................................... 532 COMMUNITY HEALTH NURSING Part 1........................ 444 Nursing Research Suggested Answer Key ................ 546 COMMUNITY HEALTH NURSING Part 2........................ 454 2 NURSING RESEARCH Part 2 .......................................... 542
  • 3. 3
  • 4. 5. NURSING PRACTICE I: FOUNDATION OF NURSING PRACTICE SITUATION: Nursing is a profession. The nurse should have a background on the theories and foundation of nursing as it influenced what is nursing today. 1. 2. 3. 4. 4 Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of the individuals, families, communities and the population. This is the most accepted definition of nursing as defined by the: a. PNA b. ANA c. Nightingale d. Henderson Advancement in Nursing leads to the development of the Expanded Career Roles. Which of the following is NOT an expanded career role for nurses? a. Nurse practitioner b. Nurse Researcher c. Clinical nurse specialist d. Nurse anaesthesiologist The Board of Nursing regulated the Nursing profession in the Philippines and is responsible for the maintenance of the quality of nursing in the country. Powers and duties of the board of nursing are the following, EXCEPT: a. Issue, suspend, revoke certificates of registration b. Issue subpoena duces tecum, ad testificandum c. Open and close colleges of nursing d. Supervise and regulate the practice of nursing A nursing student or a beginning staff nurse who has not yet experienced enough real situations to make judgments about them is in what stage of Nursing Expertise? a. Novice b. Newbie c. Advanced Beginner d. Competent Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having: a. the ability to organize and plan activities b. having attained an advanced level of education c. a holistic understanding and perception of the client d. intuitive and analytic ability in new situations SITUATION: The nurse has been asked to administer an injection via Z TRACK technique. Questions 6 to 10 refer to this. 6. The nurse prepares an IM injection for an adult client using the Z track technique. 4 ml of medication is to be administered to the client. Which of the following site will you choose? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 7. In infants 1 year old and below, which of the following is the site of choice for intramuscular Injection? a. Deltoid b. Rectus femoris c. Ventrogluteal d. Vastus lateralis 8. In order to decrease discomfort in Z track administration, which of the following is applicable? a. Pierce the skin quickly and smoothly at a 90 degree angle b. Inject the medication steadily at around 10 minutes per millilitre c. Pull back the plunger and aspirate for 1 minute to make sure that the needle did not hit a blood vessel d. Pierce the skin slowly and carefully at a 90 degree angle 9. After injection using the Z track technique, the nurse should know that she needs to wait for a few seconds before withdrawing the needle and this is to allow the medication to disperse into the muscle tissue, thus decreasing the client’s discomfort. How many seconds should the nurse wait before withdrawing the needle? a. 2 seconds
  • 5. 5 b. 5 seconds c. 10 seconds d. 15 seconds 10. The rationale in using the Z track technique in an intramuscular injection is: a. It decreases the leakage of discolouring and irritating medication into the subcutaneous tissues b. It will allow a faster absorption of the medication c. The Z track technique prevent irritation of the muscle d. It is much more convenient for the nurse that the patient smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading? a. 15 minutes b. 30 minutes c. 1 hour d. 5 minutes 15. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to: a. Set and turn on the alarm of the oximeter b. Do nothing since there is no identified problem c. Cover the fingertip sensor with a towel or bedsheet d. Change the location of the sensor every four hours 16. The nurse finds it necessary to recheck the blood pressure reading. In case of such re assessment, the nurse should wait for a period of: a. 15 seconds b. 1 to 2 minutes c. 30 minutes d. 15 minutes 17. If the arm is said to be elevated when taking the blood pressure, it will create a: a. False high reading b. False low reading c. True false reading d. Indeterminate 18. You are to assessed the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature? a. 10 minutes b. 20 minutes c. 30 minutes d. 15 minutes 19. When auscultating the client’s blood pressure the nurse hears the following: From 150 mmHg to 130 mmHg: Silence, Then: a thumping sound continuing down to 100 mmHg; muffled sound continuing down to 80 mmHg and then silence. SITUATION: A Client was rushed to the emergency room and you are his attending nurse. You are performing a vital sign assessment. 11. 12. 13. 14. All of the following are correct methods in assessment of the blood pressure EXCEPT: a. Take the blood pressure reading on both arms for comparison b. Listen to and identify the phases of Korotkoff’s sound c. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated d. Observe procedures for infection control You attached a pulse oximeter to the client. You know that the purpose is to: a. Determine if the client’s hemoglobin level is low and if he needs blood transfusion b. Check level of client’s tissue perfusion c. Measure the efficacy of the client’s antihypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops After a few hours in the Emergency Room, The client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: a. inconsistent b. low systolic and high diastolic c. higher than what the reading should be d. lower than what the reading should be Through the client’s health history, you gather
  • 6. What is the client’s blood pressure? a. 130/80 b. 150/100 c. 100/80 d. 150/100 20. In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading? a. 10-20 seconds b. 30-45 seconds c. 1-1.5 minutes d. 3-3.5 minutes to lungs. This can be avoided by: a. Cleaning teeth and mouth with cotton swabs soaked with mouthwash to avoid rinsing the buccal cavity b. swabbing the inside of the cheeks and lips, tongue and gums with dry cotton swabs c. use fingers wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and ums d. suctioning as needed while cleaning the buccal cavity 25. Situation: Oral care is an important part of hygienic practices and promoting client comfort. 21. 22. 23. 24. 6 An elderly client, 84 years old, is unconscious. Assessment of the mouth reveals excessive dryness and presence of sores. Which of the following is BEST to use for oral care? a. lemon glycerine b. Mineral oil c. hydrogen peroxide d. Normal saline solution When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs? a. Put the client on a sidelying position with head of bed lowered b. Keep the client dry by placing towel under the chin c. Wash hands and observes appropriate infection control d. Clean mouth with oral swabs in a careful and an orderly progression The advantages of oral care for a client include all of the following, EXCEPT: a. decreases bacteria in the mouth and teeth b. reduces need to use commercial mouthwash which irritate the buccal mucosa c. improves client’s appearance and selfconfidence d. improves appetite and taste of food A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using: a. salt solution b. petroleum jelly c. water d. mentholated ointment Situation – Ensuring safety before, during and after a diagnostic procedure is an important responsibility of the nurse. 26. To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure? a. Clenching his fist every 2 minutes b. Breathing in and out through the nose with his mouth open c. Tensing the shoulder muscles while lying on his back d. Holding his breath periodically for 30 seconds 27. Following a bronchoscopy, which of the following complains to Fernan should be noted as a possible complication: a. Nausea and vomiting b. Shortness of breath and laryngeal stridor c. Blood tinged sputum and coughing d. Sore throat and hoarseness 28. Immediately after bronchoscopy, you instructed Fernan to: a. Exercise the neck muscles b. Refrain from coughing and talking
  • 7. 7 c. Breathe deeply d. Clear his throat d. Weber’s test 34. 29. 30. Right after thoracentesis, which of the following is most appropriate intervention? a. Instruct the patient not to cough or deep breathe for two hours b. Observe for symptoms of tightness of chest or bleeding c. Place an ice pack to the puncture site d. Remove the dressing to check for bleeding A nurse is reviewing the arterial blood gas values of a client and notes that the ph is 7.31, Pco2 is 50 mmHg, and the bicarbonate is 27 mEq/L. The nurse concludes that which acid base disturbance is present in this client? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 35. Allen’s test checks the patency of the: a. Ulnar artery b. Carotid artery c. Radial artery d. Brachial artery Thoracentesis may be performed for cytologic study of pleural fluid. As a nurse your most important function during the procedure is to: a. Keep the sterile equipment from contamination b. Assist the physician c. Open and close the three-way stopcock d. Observe the patient’s vital signs Situation: Knowledge of the acid-base disturbance and the functions of the electrolytes is necessary to determine appropriate intervention and nursing actions. 31. A client with diabetes milletus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is at most risk for the development of which type of acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 32. In a client in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, PCO2 32 mmHg, PO2 94 mmHg, HCO3 24 mEq/L. The nurse interprets that the client has which acid base disturbance? a. Respiratory acidosis b. Metabolic acidosis c. Respiratory alkalosis d. Metabolic alkalosis 33. A client has an order for ABG analysis on radial artery specimens. The nurse ensures that which of the following has been performed or tested before the ABG specimens are drawn? a. Guthrie test b. Romberg’s test c. Allen’s test Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 36. Given the above assessment data, the most immediate goal of the nurse would be which of the following? a. Prevent urinary complication b. maintains fluid and electrolytes c. Alleviate pain d. Alleviating nausea 37. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post-operative order includes “daily urine specimen to be sent to the laboratory”. Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? a. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container b. empty a sample urine from the collecting bag into the specimen container c. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. d. Disconnect the drainage from the collecting bag and allow the urine to flow from the catheter into the specimen container.
  • 8. 38. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation? a. to the patient’s inner thigh b. to the patient’ buttocks c. to the patient’s lower thigh d. to the patient lower abdomen regulation is secreted in the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland 45. 39. 40. Which of the following menu is appropriate for one with low sodium diet? a. instant noodles, fresh fruits and ice tea b. ham and cheese sandwich, fresh fruits and vegetables c. white chicken sandwich, vegetable salad and tea d. canned soup, potato salad, and diet soda How will you prevent ascending infection to Eileen who has an indwelling catheter? a. see to it that the drainage tubing touches the level of the urine b. change he catheter every eight hours c. see to it that the drainage tubing does not touch the level of the urine d. clean catheter may be used since urethral meatus is not a sterile area Situation: Hormones are secreted by the various glands in the body. Basic knowledge of the endocrine system is necessary. 41. All of the following are secreted by the anterior pituitary gland except: a. Somatotropin/Growth hormone b. Thyroid stimulating hormone c. Follicle stimulating hormone d. Gonadotropin hormone releasing hormone Situation: The staff nurse supervisor requests all the staff nurses to “brainstorm” and learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure that there are nurses available daily to do health education classes. 46. The plan of the nurse supervisor is an example of a. in service education process b. efficient management of human resources c. increasing human resources d. primary prevention 47. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra a. makes the assignment to teach the staff member b. is assigning the responsibility to the aide but not the accountability for those tasks c. does not have to supervise or evaluate the aide d. most know how to perform task delegated 48. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six weeks ago when she started the job. The nurse supervisor should a. empathize with the nurse and listen to her b. tell her to take the day off c. discuss how she is adjusting to her new job d. ask about her family life 49. Process of formal negotiations of working conditions between a group of registered nurses and employer is Somatocrinin or the Growth hormone releasing hormone is secreted by the: a. Hypothalamus b. Posterior pituitary gland c. Anterior pituitary gland d. Thyroid gland 42. 43. 44. 8 All of the following hormones are hormones secreted by the Posterior pituitary gland except: a. Vasopressin b. Anti-diuretic hormone c. Oxytocin d. Growth hormone Calcitonin, a hormone necessary for calcium While Parathormone, a hormone that negates the effect of calcitonin is secreted by the: a. Thyroid gland b. Parathyroid gland c. Hypothalamus d. Anterior pituitary gland
  • 9. 9 a. b. c. d. grievance arbitration collective bargaining strike d. It should disclose previous diagnosis, prognosis and alternative treatments available for the client 55. 50. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is a. professional course towards credits b. in-service education c. advance training d. continuing education Situation: As a nurse, you are aware that proper documentation in the patient chart is your responsibility. 51. 52. 53. 54. Which of the following is not a legally binding document but nevertheless very important in the care of all patients in any health care setting? a. Bill of rights as provided in the Philippine constitution b. Scope of nursing practice as defined by RA 9173 c. Board of nursing resolution adopting the code of ethics d. Patient’s bill of rights A nurse gives a wrong medication to the client. Another nurse employed by the same hospital as a risk manager will expect to receive which of the following communication? a. Incident report b. Nursing kardex c. Oral report d. Complain report Performing a procedure on a client in the absence of an informed consent can lead to which of the following charges? a. Fraud b. Harassment c. Assault and battery d. Breach of confidentiality Which of the following is the essence of informed consent? a. It should have a durable power of attorney b. It should have coverage from an insurance company c. It should respect the client’s freedom from coercion Delegation is the process of assigning tasks that can be performed by a subordinate. The RN should always be accountable and should not lose his accountability. Which of the following is a role included in delegation? a. The RN must supervise all delegated tasks b. After a task has been delegated, it is no longer a responsibility of the RN c. The RN is responsible and accountable for the delegated task in adjunct with the delegate d. Follow up with a delegated task is necessary only if the assistive personnel is not trustworthy Situation: When creating your lesson plan for cerebrovascular disease or STROKE. It is important to include the risk factors of stroke. 56. The most important risk factor is: a. Cigarette smoking b. binge drinking c. Hypertension d. heredity 57. Part of your lesson plan is to talk about etiology or cause of stroke. The types of stroke based on cause are the following EXCEPT: a. Embolic stroke b. diabetic stroke c. Hemorrhagic stroke d. thrombotic stroke 58. Hemmorhagic stroke occurs suddenly usually when the person is active. All are causes of hemorrhage, EXCEPT: a. phlebitis b. damage to blood vessel c. trauma d. aneurysm 59. The nurse emphasizes that intravenous drug abuse carries a high risk of stroke. Which drug is closely linked to this? a. Amphetamines b. shabu c. Cocaine d. Demerol
  • 10. d. Iron 75 mg/100 ml 60. A participant in the STROKE class asks what is a risk factor of stroke. Your best response is: a. “More red blood cells thicken blood and make clots more possible.” b. “Increased RBC count is linked to high cholesterol.” c. “More red blood cell increases hemoglobin content.” d. “High RBC count increases blood pressure.” Situation: Recognition of normal values is vital in assessment of clients with various disorders. 61. A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 5.6 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. ST depression b. Prominent U wave c. Inverted T wave d. Tall peaked T waves 63. 64. 10 A nurse is reviewing the electrolyte results of an assigned client and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse expect to note on the ECG as a result of this laboratory value? a. U waves b. Elevated T waves c. Absent P waves d. Elevated ST Segment Dorothy underwent diagnostic test and the result of the blood examination are back. On reviewing the result the nurse notices which of the following as abnormal finding? a. Neutrophils 60% b. White blood cells (WBC) 9000/mm c. Erythrocyte sedimentation rate (ESR) is 39 mm/hr Which of the following laboratory test result indicate presence of an infectious process? a. Erythrocyte sedimentation rate (ESR) 12 mm/hr b. White blood cells (WBC) 18,000/mm3 c. Iron 90 g/100ml d. Neutrophils 67% Situation: Pleural effusion is the accumulation of fluid in the pleural space. Questions 66 to 70 refer to this. 66. Which of the following is a finding that the nurse will be able to assess in a client with Pleural effusion? a. Reduced or absent breath sound at the base of the lungs, dyspnea, tachpynea and shortness of breath b. Hypoxemia, hypercapnea and respiratory acidosis c. Noisy respiration, crackles, stridor and wheezing d. Tracheal deviation towards the affected side, increased fremitus and loud breath sounds 67. Thoracentesis is performed to the client with effusion. The nurse knows that the removal of fluid should be slow. Rapid removal of fluid in thoracentesis might cause: a. Pneumothorax b. Cardiovascular collapse c. Pleurisy or Pleuritis d. Hypertension 68. 3 Days after thoracentesis, the client again exhibited respiratory distress. The nurse will know that pleural effusion has reoccurred when she noticed a sharp stabbing pain during inspiration. The physician ordered a closed tube thoracotomy for the client. The nurse knows that the primary function of the chest tube is to: a. Restore positive intrathoracic pressure b. Restore negative intrathoracic pressure c. To visualize the intrathoracic content d. As a method of air administration via ventilator 69. The chest tube is functioning properly if: a. There is an oscillation b. There is no bubbling in the drainage bottle A nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse would expect the hematocrit level for this client to be which of the following? a. 60% b. 47% c. 45% d. 32% 62. 65.
  • 11. 11 c. There is a continuous bubbling in the waterseal d. The suction control bottle has a continuous bubbling 70. In a client with pleural effusion, the nurse is instructing appropriate breathing technique. Which of the following is included in the teaching? a. Breath normally b. Hold the breath after each inspiration for 1 full minute c. Practice abdominal breathing d. Inhale slowly and hold the breath for 3 to 5 seconds after each inhalation 75. This form of Health Insurance provides comprehensive prepaid health services to enrollees for a fixed periodic payment. a. Health Maintenance Organization b. Medicare c. Philippine Health Insurance Act d. Hospital Maintenance Organization Situation: Nursing ethics is an important part of the nursing profession. As the ethical situation arises, so is the need to have an accurate and ethical decision making. 76. The purpose of having a nurses’ code of ethics is: a. Delineate the scope and areas of nursing practice b. identify nursing action recommended for specific health care situations c. To help the public understand professional conduct expected of nurses d. To define the roles and functions of the health care givers, nurses, clients 77. The principles that govern right and proper conduct of a person regarding life, biology and the health professionals is referred to as: a. Morality b. Religion c. Values d. Bioethics 78. A subjective feeling about what is right or wrong is said to be: a. Morality b. Religion c. Values d. Bioethics 79. Values are said to be the enduring believe about a worth of a person, ideas and belief. If Values are going to be a part of a research, this is categorized under: a. Qualitative b. Experimental c. Quantitative d. Non Experimental 80. The most important nursing responsibility where ethical situations emerge in patient care is to: a. Act only when advised that the action is ethically sound SITUATION: Health care delivery system affects the health status of every filipino. As a Nurse, Knowledge of this system is expected to ensure quality of life. 71. When should rehabilitation commence? a. The day before discharge b. When the patient desires c. Upon admission d. 24 hours after discharge 72. What exemplified the preventive and promotive programs in the hospital? a. Hospital as a center to prevent and control infection b. Program for smokers c. Program for alcoholics and drug addicts d. Hospital Wellness Center 73. Which makes nursing dynamic? a. Every patient is a unique physical, emotional, social and spiritual being b. The patient participate in the overall nursing care plan c. Nursing practice is expanding in the light of modern developments that takes place d. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes 74. Prevention is an important responsibility of the nurse in: a. Hospitals b. Community c. Workplace d. All of the above
  • 12. b. Not takes sides, remain neutral and fair c. Assume that ethical questions are the responsibility of the health team d. Be accountable for his or her own actions 81. 82. 83. 84. 12 Why is there an ethical dilemma? a. the choices involved do not appear to be clearly right or wrong b. a client’s legal right co-exist with the nurse’s professional obligation c. decisions has to be made based on societal norms. d. decisions has to be mad quickly, often under stressful conditions According to the code of ethics, which of the following is the primary responsibility of the nurse? a. Assist towards peaceful death b. Health is a fundamental right c. Promotion of health, prevention of illness, alleviation of suffering and restoration of health d. Preservation of health at all cost Which of the following is TRUE about the Code of Ethics of Filipino Nurses, except: a. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated b. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates c. The present code utilized the Code of Good Governance for the Professions in the Philippines d. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the license? a. PRC b. PNA c. DOH d. BON 85. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability? a. Human rights of clients, regardless of creed and gender b. The privilege of being a registered professional nurse c. Health, being a fundamental right of every individual d. Accurate documentation of actions and outcomes Situation: As a profession, nursing is dynamic and its practice is directed by various theoretical models. To demonstrate caring behaviour, the nurse applies various nursing models in providing quality nursing care. 86. When you clean the bedside unit and regularly attend to the personal hygiene of the patient as well as in washing your hands before and after a procedure and in between patients, you indent to facilitate the body’s reparative processes. Which of the following nursing theory are you applying in the above nursing action? a. Hildegard Peplau b. Dorothea Orem c. Virginia Henderson d. Florence Nightingale 87. A communication skill is one of the important competencies expected of a nurse. Interpersonal process is viewed as human to human relationship. This statement is an application of whose nursing model? a. Joyce Travelbee b. Martha Rogers c. Callista Roy d. Imogene King 88. The statement “the health status of an individual is constantly changing and the nurse must be cognizant and responsive to these changes” best explains which of the following facts about nursing? a. Dynamic b. Client centred c. Holistic d. Art 89. Virginia Henderson professes that the goal of nursing is to work interdependently with other health care working in assisting the patient to
  • 13. 13 gain independence as quickly as possible. Which of the following nursing actions best demonstrates this theory in taking care of a 94 year old client with dementia who is totally immobile? a. Feeds the patient, brushes his teeth, gives the sponge bath b. Supervise the watcher in rendering patient his morning care c. Put the patient in semi fowler’s position, set the over bed table so the patient can eat by himself, brush his teeth and sponge himself d. Assist the patient to turn to his sides and allow him to brush and feed himself only when he feels ready include: a. Prescription of the doctor to the patient’s illness b. Plan of care for patient c. Patient’s perception of one’s illness d. Nursing problem and Nursing diagnosis The medical records that are organized into separate section from doctors or nurses has more disadvantages than advantages. This is classified as what type of recording? a. POMR b. Modified POMR c. SOAPIE d. SOMR 95. 90. 94. Which of the following is the advantage of SOMR or Traditional recording? a. Increases efficiency in data gathering b. Reinforces the use of the nursing process c. The caregiver can easily locate proper section for making charting entries d. Enhances effective communication among health care team members In the self-care deficit theory by Dorothea Orem, nursing care becomes necessary when a patient is unable to fulfil his physiological, psychological and social needs. A pregnant client needing prenatal check-up is classified as: a. Wholly compensatory b. Supportive Educative c. Partially compensatory d. Non compensatory Situation: Documentation and reporting are just as important as providing patient care, As such, the nurse must be factual and accurate to ensure quality documentation and reporting. Situation: June is a 24 year old client with symptoms of dyspnea, absent breath sounds on the right lung and chest x ray revealed pleural effusion. The physician will perform thoracentesis. 96. 91. Health care reports have different purposes. The availability of patients’ record to all health team members demonstrates which of the following purposes: a. Legal documentation b. Research c. Education d. Vehicle for communication 92. POMR has been widely used in many teaching hospitals. One of its unique features is SOAPIE charting. The P in SOAPIE charting should 97. Which of the following psychological preparation is not relevant for him? a. Telling him that the gauge of the needle and anesthesia to be used b. Telling him to keep still during the procedure to facilitate the insertion of the needle in the correct place c. Allow June to express his feelings and concerns d. Physician’s explanation on the purpose of the procedure and how it will be done 98. Before thoracentesis, the legal consideration you must check is: a. Consent is signed by the client When a nurse commits medication error, she should accurately document client’s response and her corresponding action. This is very important for which of the following purposes: a. Research b. Legal documentation c. Nursing Audit d. Vehicle for communication 93. Thoracentesis is useful in treating all of the following pulmonary disorders except: a. Hemothorax b. Hydrothorax c. Tuberculosis d. Empyema
  • 14. b. Medicine preparation is correct c. Position of the client is correct d. Consent is signed by relative and physician 99. As a nurse, you know that the position for June before thoracentesis is: a. Orthopneic b. Low fowlers c. Knee-chest d. Sidelying position on the affected side 100. Which of the following anaesthetics drug is used for thoracentesis? a. Procaine 2% b. Demerol 75 mg c. Valium 250 mg d. Phenobartbital 50 mg 14
  • 15. 15 D. Follicle stimulating hormone NURSING PRACTICE II Situation: Mariah is a 31 year old lawyer who has been married for 6 months. She consults you for guidance in relation with her menstrual cycle and her desire to get pregnant. 1. She wants to know the length of her menstrual cycle. Her previous menstrual period is October 22 to 26. Her LMB is November 21. Which of the following number of days will be your correct response? A. 29 B. 28 C. 30 D. 31 2. You advised her to observe and record the signs of Ovulation. Which of the following signs will she likely note down? 1. A 1 degree Fahrenheit rise in basal body temperature 2. Cervical mucus becomes copious and clear 3. One pound increase in weight 4. Mittelschmerz A. 1, 2, 4 B. 1, 2, 3 C. 2, 3, 4 D. 1, 3, 4 3. You instruct Mariah to keep record of her basal temperature every day, which of the following instructions is incorrect? A. If coitus has occurred; this should be reflected in the chart B. It is best to have coitus on the evening following a drop in BBT to become pregnant C. Temperature should be taken immediately after waking and before getting out of bed D. BBT is lowest during the secretory phase 4. She reports an increase in BBT on December 16. Which hormone brings about this change in her BBT? A. Estrogen B. Gonadotropine C. Progesterone 5. The following month, Mariah suspects she is pregnant. Her urine is positive for Human chorionic gonadotrophin. Which structure produces Hcg? A. Pituitary gland B. Trophoblastic cells of the embryo C. Uterine deciduas D. Ovarian follicles Situation: Mariah came back and she is now pregnant. 6. At 5 month gestation, which of the following fetal development would probably be achieve? A. Fetal movement are felt by Mariah B. Vernix caseosa covers the entire body C. Viable if delivered within this period D. Braxton hicks contractions are observed 7. The nurse palpates the abdomen of Mariah. Now At 5 month gestation, What level of the abdomen can the fundic height be palpated? A. Symphysis pubis B. Midpoint between the umbilicus and the xiphoid process C. Midpoint between the symphysis pubis and the umbilicus D. Umbilicus 8. She worries about her small breasts, thinking that she probably will not be able to breastfeed her baby. Which of the following responses of the nurse is correct? A. “The size of your breast will not affect your lactation” B. “You can switch to bottle feeding” C. “You can try to have exercise to increase the size of your breast” D. “Manual expression of milk is possible” 9. She tells the nurse that she does not take milk regularly. She claims that she does not want to gain too much weight during her pregnancy. Which of the following nursing diagnosis is a priority? A. Potential self-esteem disturbance related to physiologic changes in pregnancy B. Ineffective individual coping related to physiologic changes in pregnancy C. Fear related to the effects of pregnancy D. Knowledge deficit regarding nutritional
  • 16. requirements of pregnancies related to lack of information sources 10. Which of the following interventions will likely ensure compliance of Mariah? A. Incorporate her food preferences that are adequately nutritious in her meal plan B. Consistently counsel toward optimum nutritional intake C. Respect her right to reject dietary information if she chooses D. Inform her of the adverse effects of inadequate nutrition to her fetus Situation: Susan is a patient in the clinic where you work. She is inquiring about pregnancy. 11. Susan tells you she is worried because she develops breasts later than most of her friends. Breast development is termed as: A. Adrenarche B. Thelarche C. Mamarche D. Menarche 12. Kevin, Susan’s husband tells you that he is considering vasectomy After the birth of their new child. Vasectomy involves the incision of which organ? A. The testes B. The epididymis C. The vas deferens D. The scrotum 13. On examination, Susan has been found of having a cystocele. A cystocele is: A. A sebaceous cyst arising from the vulvar fold B. Protrusion of intestines into the vagina C. Prolapse of the uterus into the vagina D. Herniation of the bladder into the vaginal wall 14. Susan typically has menstrual cycle of 34 days. She told you she had coitus on days 8, 10, 15 and 20 of her menstrual cycle. Which is the day on which she is most likely to conceive? A. 8th day B. Day 15 C. 10th day D. Day 20 16 15. While talking with Susan, 2 new patients arrived and they are covered with large towels and the nurse noticed that there are many cameraman and news people outside of the OPD. Upon assessment the nurse noticed that both of them are still nude and the male client’s penis is still inside the female client’s vagina and the male client said that “I can’t pull it”. Vaginismus was your first impression. You know that The psychological cause of Vaginismus is related to: A. The male client inserted the penis too deeply that it stimulates vaginal closure B. The penis was too large that is why the vagina triggered its defense to attempt to close it C. The vagina does not want to be penetrated D. It is due to learning patterns of the female client where she views sex as bad or sinful Situation: Overpopulation is one problem in the Philippines that causes economic drain. Most Filipinos are against in legalizing abortion. As a nurse, Mastery of contraception is needed to contribute to the society and economic growth. 16. Supposed that Dana, 17 years old, tells you she wants to use fertility awareness method of contraception. How will she determine her fertile days? A. She will notice that she feels hot, as if she has an elevated temperature. B. She should assess whether her cervical mucus is thin, copious, clear and watery. C. She should monitor her emotions for sudden anger or crying D. She should assess whether her breasts feel sensitive to cool air 17. Dana chooses to use COC as her family planning method. What is the danger sign of COC you would ask her to report? A. A stuffy or runny nose B. Slight weight gain C. Arthritis like symptoms D. Migraine headache 18. Dana asks about subcutaneous implants and she asks, how long will these implants be effective. Your best answer is: A. One month
  • 17. 17 B. Five years C. Twelve months D. 10 years 19. Dana asks about female condoms. Which of the following is true with regards to female condoms? A. The hormone the condom releases might cause mild weight gain B. She should insert the condom before any penile penetration C. She should coat the condom with spermicide before use D. Female condoms, unlike male condoms, are reusable 20. Dana has asked about GIFT procedure. What makes her a good candidate for GIFT? A. She has patent fallopian tubes, so fertilized ova can be implanted on them B. She is RH negative, a necessary stipulation to rule out RH incompatibility C. She has normal uterus, so the sperm can be injected through the cervix into it D. Her husband is taking sildenafil, so all sperms will be motile Situation: Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. 21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer? A. Prostaglandins released from the cut fallopian tubes can kill sperm B. Sperm cannot enter the uterus because the cervical entrance is blocked. C. Sperm can no longer reach the ova, because the fallopian tubes are blocked D. The ovary no longer releases ova as there is nowhere for them to go. 22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when: A. A woman has no uterus B. A woman has no children C. A couple has been trying to conceive for 1 year D. A couple has wanted a child for 6 months 23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because: A. Endometrial implants can block the fallopian tubes B. The uterine cervix becomes inflamed and swollen C. The ovaries stop producing adequate estrogen D. Pressure on the pituitary leads to decreased FSH levels 24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure? A. She will not be able to conceive for 3 months after the procedure B. The sonogram of the uterus will reveal any tumors present C. Many women experience mild bleeding as an after effect D. She may feel some cramping when the dye is inserted 25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. Donor sperm are introduced vaginally into the uterus or cervix B. Donor sperm are injected intraabdominally into each ovary C. Artificial sperm are injected vaginally to test tubal patency D. The husband’s sperm is administered intravenously weekly Situation: You are assigned to take care of a group of patients across the lifespan. 26. Pain in the elder persons requires careful assessment because they: A. experienced reduce sensory perception B. have increased sensory perception C. are expected to experience chronic pain D. have a decreased pain threshold 27. Administration of analgesics to the older persons requires careful patient assessment because older people: A. are more sensitive to drugs
  • 18. B. have increased hepatic, renal and gastrointestinal function C. have increased sensory perception D. mobilize drugs more rapidly 28. The elderly patient is at higher risk for urinary incontinence because of: A. increased glomerular filtration B. decreased bladder capacity C. diuretic use D. dilated urethra 29. Which of the following is the MOST COMMON sign of infection among the elderly? A. decreased breath sounds with crackles B. pain C. fever D. change in mental status 30. Priorities when caring for the elderly trauma patient: A. circulation, airway, breathing B. airway, breathing, disability (neurologic) C. disability (neurologic), airway, breathing D. airway, breathing, circulation 31. Preschoolers are able to see things from which of the following perspectives? A. Their peers B. Their own and their mother’s C. Their own and their caregivers’ D. Only their own 32. In conflict management, the win-win approach occurs when: A. There are two conflicts and the parties agree to each one B. Each party gives in on 50% of the disagreements making up the conflict C. Both parties involved are committed to solving the conflict D. The conflict is settled out of court so the legal system and the parties win 33. According to the social-interactional perspective of child abuse and neglect, four factors place the family members at risk for abuse. These risk factors are the family members at risk for abuse. These risk factors are the family itself, the caregiver, the child, and A. The presence of a family crisis B. The national emphasis on sex C. Genetics 18 D. Chronic poverty 34. Which of the following signs and symptoms would you most likely find when assessing and infant with Arnold-Chiari malformation? A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting. 35. A parent calls you and frantically reports that her child has gotten into her famous ferrous sulfate pills and ingested a number of these pills. Her child is now vomiting, has bloody diarrhea, and is complaining of abdominal pain. You will tell the mother to: A. Call emergency medical services (EMS) and get the child to the emergency room B. Relax because these symptoms will pass and the child will be fine C. Administer syrup of ipecac D. Call the poison control center 36. A client says she heard from a friend that you stop having periods once you are on the “pill”. The most appropriate response would be: A. “The pill prevents the uterus from making such endometrial lining, that is why periods may often be scant or skipped occasionally.” B. “If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible.” C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly.” D. “Missed period can be very dangerous and may lead to the formation of precancerous cells.” 37. The nurse assessing newborn babies and infants during their hospital stay after birth will notice which of the following symptoms as a primary manifestation of Hirschsprung’s disease? A. A fine rash over the trunk B. Failure to pass meconium during the first 24 to 48 hours after birth
  • 19. 19 C. The skin turns yellow and then brown over the first 48 hours of life D. High-grade fever 38. A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She is stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching? A. Maintain bed rest with bathroom privileges B. Avoid intercourse for three days. C. Call if contractions occur. D. Stay on left side as much as possible when lying down. 39. A woman has been rushed to the hospital with ruptured membrane. Which of the following should the nurse check first? A. Check for the presence of infection B. Assess for Prolapse of the umbilical cord C. Check the maternal heart rate D. Assess the color of the amniotic fluid 40. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical medication were to be prescribed and it were to go on the stomachs or buttocks, the nurse would teach the caregivers to: A. avoid covering the area of the topical medication with the diaper B. avoid the use of clothing on top of the diaper C. put the diaper on as usual D. apply an icepack for 5 minutes to the outside of the diaper 41. Which of the following factors is most important in determining the success of relationships used in delivering nursing care? A. Type of illness of the client B. Transference and counter transference C. Effective communication D. Personality of the participants 42. Grace sustained a laceration on her leg from automobile accident. Why are lacerations of lower extremities potentially more serious among pregnant women than other? A. lacerations can provoke allergic responses due to gonadotropic hormone release B. a woman is less able to keep the laceration clean because of her fatigue C. healing is limited during pregnancy so these will not heal until after birth D. increased bleeding can occur from uterine pressure on leg veins 43. In working with the caregivers of a client with an acute or chronic illness, the nurse would: A. Teach care daily and let the caregivers do a return demonstration just before discharge B. Difficulty swallowing, diminished or absent gag reflex, and respiratory distress. C. Difficulty sleeping, hypervigilant, and an arching of the back D. Paradoxical irritability, diarrhea, and vomiting 44. Which of the following roles BEST exemplifies the expanded role of the nurse? A. Circulating nurse in surgery B. Medication nurse C. Obstetrical nurse D. Pediatric nurse practitioner 45. According to DeRosa and Kochura’s (2006) article entitled “Implement Culturally Competent Health Care in your work place,” cultures have different patterns of verbal and nonverbal communication. Which difference does? A. NOT necessarily belong? B. Personal behavior C. Subject matter D. Eye contact E. Conversational style 46. You are the nurse assigned to work with a child with acute glomerulonephritis. By following the prescribed treatment regimen, the child experiences a remission. You are now checking to make sure the child does not have a relapse. Which finding would most lead you to the conclusion that a relapse is happening? A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with diiferential B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found to have 3-4+ proteinutria plus edema.
  • 20. C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in urine output, and a moon face. D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency on voiding, and cloudy urine. 47. The nurse is working with an adolescent who complains of being lonely and having a lack of fulfillment in her life. This adolescent shies away from intimate relationships at times yet at other times she appears promiscuous. The nurse will likely work with this adolescent in which of the following areas? A. Isolation B. Lack of fulfillment C. Loneliness D. Identity 48. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role of a licensed health care professional in the context of public health welfare and safety is an example of: A. Delegation B. Responsibility C. Supervision D. Competence 49. The painful phenomenon known as “back labor” occurs in a client whose fetus in what position? A. Brow position B. Breech position C. Right Occipito-Anterior Position D. Left Occipito-Posterior Position 50. FOCUS methodology stands for: A. Focus, Organize, Clarify, Understand and Solution B. Focus, Opportunity, Continuous, Utilize, Substantiate C. Focus, Organize, Clarify, Understand, Substantiate D. Focus, Opportunity, Continuous (process), Understand, Solution SITUATION: The infant and child mortality rate in the low to middle income countries is ten times higher than industrialized countries. In response to this, the WHO and UNICEF launched the protocol Integrated Management of Childhood Illnesses to reduce the morbidity and mortality against childhood illnesses. 20 51. If a child with diarrhea registers two signs in the yellow row in the IMCI chart, we can classify the patient as: A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 52. Celeste has had diarrhea for 8 days. There is no blood in the stool, he is irritable, his eyes are sunken, the nurse offers fluid to Celeste and he drinks eagerly. When the nurse pinched the abdomen it goes back slowly. How will you classify Celeste’s illness? A. Moderate dehydration B. Severe dehydration C. Some dehydration D. No dehydration 53. A child who is 7 weeks has had diarrhea for 14 days but has no sign of dehydration is classified as: A. Persistent diarrhea B. Dysentery C. Severe dysentery D. Severe persistent diarrhea 54. The child with no dehydration needs home treatment. Which of the following is not included in the rules for home treatment in this case? A. Forced fluids B. When to return C. Give vitamin A supplement D. Feeding more 55. Fever as used in IMCI includes: A. Axillary temperature of 37.5 or higher B. Rectal temperature of 38 or higher C. Feeling hot to touch D. All of the above E. A and C only Situation: Prevention of Dengue is an important nursing responsibility and controlling it’s spread is a priority once outbreak has been observed. 56. An important role of the community health nurse in the prevention and control of Dengue H-fever includes: A. Advising the elimination of vectors by keeping water containers covered
  • 21. 21 B. Conducting strong health education drives/campaign directed towards proper garbage disposal C. Explaining to the individuals, families, groups and community the nature of the disease and its causation D. Practicing residual spraying with insecticides 57. Community health nurses should be alert in observing a Dengue suspect. The following is NOT an indicator for hospitalization of H-fever suspects? A. Marked anorexia, abdominal pain and vomiting B. Increasing hematocrit count C. Cough of 30 days D. Persistent headache 58. The community health nurses’ primary concern in the immediate control of hemorrhage among patients with dengue is: A. Advising low fiber and non-fat diet B. Providing warmth through light weight covers C. Observing closely the patient for vital signs leading to shock D. Keeping the patient at rest 59. Which of these signs may NOT be REGARDED as a truly positive signs indicative of Dengue Hfever? A. Prolonged bleeding time B. Appearance of at least 20 petechiae within 1cm square C. Steadily increasing hematocrit count D. Fall in the platelet count 60. Which of the following is the most important treatment of patients with Dengue H-fever? A. Give aspirin for fever B. Replacement of body fluids C. Avoid unnecessary movement of patient D. Ice cap over the abdomen in case of melena Situation: Health education and Health promotion is an important part of nursing responsibility in the community. Immunization is a form of health promotion that aims at preventing the common childhood illnesses. 61. In correcting misconceptions and myths about certain diseases and their management, the health worker should first: A. Identify the myths and misconceptions prevailing in the community B. Identify the source of these myths and misconceptions C. Explain how and why these myths came about D. Select the appropriate IEC strategies to correct them 62. How many percent of measles are prevented by immunization at 9 months of age? A. 80% B. 99% C. 90% D. 95% 63. After TT3 vaccination a mother is said to be protected to tetanus by around: A. 80% B. 99% C. 85% D. 90% 64. If ever convulsions occur after administering DPT, what should the nurse best suggest to the mother? A. Do not continue DPT vaccination anymore B. Advise mother to comeback after 1 week C. Give DT instead of DPT D. Give pertussis of the DPT and remove DT 65. These vaccines are given 3 doses at one month intervals: A. DPT, BCG, TT B. OPV, HEP. B, DPT C. DPT, TT, OPV D. Measles, OPV, DPT Situation – With the increasing documented cases of CANCER the best alternative to treatment still remains to be PREVENTION. The following conditions apply. 66. Which among the following is the primary focus of prevention of cancer? A. Elimination of conditions causing cancer B. Diagnosis and treatment C. Treatment at early stage D. Early detection 67. In the prevention and control of cancer, which of the following activities is the most important
  • 22. function of the community health nurse? A. Conduct community assemblies. B. Referral to cancer specialist those clients with symptoms of cancer. C. Use the nine warning signs of cancer as parameters in our process of detection, control and treatment modalities. D. Teach woman about proper/correct nutrition. 68. Who among the following are recipients of the secondary level of care for cancer cases? A. Those under early case detection B. Those under post case treatment C. Those scheduled for surgery D. Those undergoing treatment 69. Who among the following are recipients of the tertiary level of care for cancer cases? A. Those under early treatment B. Those under early detection C. Those under supportive care D. Those scheduled for surgery 70. In Community Health Nursing, despite the availability and use of many equipment and devices to facilitate the job of the community health nurse, the best tool any nurse should be wel be prepared to apply is a scientific approach. This approach ensures quality of care even at the community setting. This is nursing parlance is nothing less than the: A. nursing diagnosis B. nursing research C. nursing protocol D. nursing process Situation – Two children were brought to you. One with chest indrawing and the other had diarrhea. The following questions apply: 71. Using Integrated Management and Childhood Illness (IMCI) approach, how would you classify the 1st child? A. Bronchopneumonia B. Severe pneumonia C. No pneumonia : cough or cold D. Pneumonia 72. The 1st child who is 13 months has fast breathing using IMCI parameters he has: A. 40 breaths per minute or more B. 50 breaths per minute 22 C. 30 breaths per minute or more D. 60 breaths per minute 73. Nina, the 2nd child has diarrhea for 5 days. There is no blood in the stool. She is irritable, and her eyes are sunken. The nurse offered fluids and and the child drinks eagerly. How would you classify Nina’s illness? A. Some dehydration B. Severe dehydration C. Dysentery D. No dehydration 74. Nina’s treatment should include the following EXCEPT: A. reassess the child and classify him for dehydration B. for infants under 6 months old who are not breastfed, give 100-200 ml clean water as well during this period C. Give in the health center the recommended amount of ORS for 4 hours. D. Do not give any other foods to the child for home treatment 75. While on treatment, Nina 18 months old weighed 18 kgs. and her temperature registered at 37 degrees C. Her mother says she developed cough 3 days ago. Nina has no general danger signs. She has 45 breaths/minute, no chest indrawing, no stridor. How would you classify Nina’s manifestation? A. No pneumonia B. Pneumonia C. Severe pneumonia D. Bronchopneumonia 76. Carol is 15 months old and weighs 5.5 kgs and it is her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using the integrated management of childhood illness or IMCI strategy, if you were the nurse in charge of Carol, how will you classify her illness? A. a child at a general danger sign B. severe pneumonia C. very severe febrile disease D. severe malnutrition 77. Why are small for gestational age newborns at
  • 23. 23 risk for difficulty maintaining body temperature? A. their skin is more susceptible to conduction of cold B. they are preterm so are born relatively small in size C. they do not have as many fat stored as other infants D. they are more active than usual so they throw off comes 78. Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure? A. headache and vomiting B. a high choking voice C. a swollen tender tongue D. abdominal bleeding and pain 79. Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever? A. use plan C if there is bleeding from the nose or gums B. give ORS if there is skin Petechiae, persistent vomiting, and positive tourniquet test C. give aspirin D. prevent low blood sugar 80. In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to: A. ask what are the child’s problem B. check for the four main symptoms C. check the patient’s level of consciousness D. check for the general danger signs 81. A child with diarrhea is observed for the following EXCEPT: A. how long the child has diarrhea B. presence of blood in the stool C. skin Petechiae D. signs of dehydration 82. The child with no dehydration needs home treatment. Which of the following is NOT included in the care for home management at this case? A. give drugs every 4 hours B. give the child more fluids C. continue feeding the child D. inform when to return to the health center 83. Ms. Jordan, RN, believes that a patient should be treated as individual. This ethical principle that the patient referred to: A. beneficence B. respect for person C. nonmaleficence D. autonomy 84. When patients cannot make decisions for themselves, the nurse advocate relies on the ethical principle of: A. justice and beneficence B. beneficence and nonmaleficence C. fidelity and nonmaleficence D. fidelity and justice 85. Being a community health nurse, you have the responsibility of participating in protecting the health of people. Consider this situation: Vendors selling bread with their bare hands. They receive money with these hands. You do not see them washing their hands. What should you say/do? A. “Miss, may I get the bread myself because you have not washed your hands” B. All of these C. “Miss, it is better to use a pick up forceps/ bread tong” D. “Miss, your hands are dirty. Wash your hands first before getting the bread” Situation: The following questions refer to common clinical encounters experienced by an entry level nurse. 86. A female client asks the nurse about the use of a cervical cap. Which statement is correct regarding the use of the cervical cap? A. It may affect Pap smear results. B. It does not need to be fitted by the physician. C. It does not require the use of spermicide. D. It must be removed within 24 hours. 87. The major components of the communication process are: A. Verbal, written and nonverbal
  • 24. B. Speaker, listener and reply C. Facial expression, tone of voice and gestures D. Message, sender, channel, receiver and feedback 88. The extent of burns in children are normally assessed and expressed in terms of: A. The amount of body surface that is unburned B. Percentages of total body surface area (TBSA) C. How deep the deepest burns are D. The severity of the burns on a 1 to 5 burn scale. 89. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes; is always hungry; has no lunch money; and is always tired. When the nurse asks the boy his tiredness, he talks of playing outside until midnight. The nurse will suspect that this child is: A. Being raised by a parent of low intelligence quotient (IQ) B. An orphan C. A victim of child neglect D. The victim of poverty 90. Which of the following indicates the type(s) of acute renal failure? A. Four types: hemorrhagic with and without clotting, and nonhemorrhagic with and without clottings B. One type: acute C. Three types: prerenal, intrarenal and postrenal D. Two types: acute and subacute Situation: Mike 16 y/o has been diagnosed to have AIDS; he worked as entertainer in a cruise ship; 91. Which method of transmission is common to contract AIDS? A. Syringe and needles B. Sexual contact C. Body fluids D. Transfusion 92. Causative organism in AIDS is one of the following; A. Fungus B. retrovirus C. Bacteria 24 D. Parasites 93. You are assigned in a private room of Mike. Which procedure should be of outmost importance; A. Alcohol wash B. Washing Isolation C. Universal precaution D. Gloving technique 94. What primary health teaching would you give to mike; A. Daily exercise B. reverse isolation C. Prevent infection D. Proper nutrition 95. Exercise precaution must be taken to protect health worker dealing with the AIDS patients . which among these must be done as priority: A. Boil used syringe and needles B. Use gloves when handling specimen C. Label personal belonging D. Avoid accidental wound Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have measles but she is at home because of fever, upper respiratory problem and white sports in her mouth. 96. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive stage prior to eruption behind the ears. As a nurse, your physical examination must determine complication especially: A. Otitis media B. Inflammatory conjunctiva C. Bronchial pneumonia D. Membranous laryngitis 97. To render comfort measure is one of the priorities, Which includes care of the skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in some form of which one below? A. Water B. Alkaline C. Sulfur D. Salt 98. As a public health nurse, you teach mother and family members the prevention of complication of measles. Which of the following should be
  • 25. 25 closely watched? A. Temperature fails to drop B. Inflammation of the nasophraynx C. Inflammation of the conjunctiva D. Ulcerative stomatitis 99. Source of infection of measles is secretion of nose and throat of infection person. Filterable virus of measles is transmitted by: A. Water supply B. Food ingestion C. Droplet D. Sexual contact 100. Method of prevention is to avoid exposure to an infection person. Nursing responsibility for rehabilitation of patient includes the provision of: A. Terminal disinfection B. Immunization C. Injection of gamma globulin D. Comfort measures
  • 26. c. 50 days d. 14 days NURSING PRACTICE III Situation: Leo lives in the squatter area. He goes to nearby school. He helps his mother gather molasses after school. One day, he was absent because of fever, malaise, anorexia and abdominal discomfort. 1. 2. 3. 4. 5. 26 Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection agent taken? a. Fecal-oral b. Droplet c. Airborne d. Sexual contact Which of the following is concurrent disinfection in the case of Leo? a. Investigation of contact b. Sanitary disposal of faeces, urine and blood c. Quarantine of the sick individual d. removing all detachable objects in the room, cleaning lighting and air duct surfaces in the ceiling, and cleaning everything downward to the floor Which of the following must be emphasized during mother’s class to Leo’s mother? a. Administration of Immunoglobulin to families b. Thorough hand washing before and after eating and toileting c. Use of attenuated vaccines d. Boiling of food especially meat Disaster control should be undertaken when there are 3 or more hepatitis A cases. Which of these measures is a priority? a. Eliminate faecal contamination from foods b. Mass vaccination of uninfected individuals c. Health promotion and education to families and communities about the disease it’s cause and transmission d. Mass administration of Immunoglobulin What is the average incubation period of Hepatitis A? a. 30 days b. 60 days Situation: As a nurse researcher you must have a very good understanding of the common terms of concept used in research. 6. The information that an investigator collects from the subjects or participants in a research study is usually called; a. Hypothesis b. Variable c. Data d. Concept 7. Which of the following usually refers to the independent variables in doing research a. Result b. output c. Cause d. Effect 8. The recipients of experimental treatment is an experimental design or the individuals to be observed in a non experimental design are called; a. Setting b. Treatment c. Subjects d. Sample 9. The device or techniques an investigator employs to collect data is called; a. Sample b. hypothesis c. Instrument d. Concept 10. The use of another person’s ideas or wordings without giving appropriate credit results from inaccurate or incomplete attribution of materials to its sources. Which of the following is referred to when another person’s idea is inappropriate credited as one’s own; a. Plagiarism b. assumption c. Quotation d. Paraphrase Situation – Mrs. Pichay is admitted to your ward. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity.”
  • 27. 27 11. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis? a. Support and reassure client during the procedure b. Ensure that informed consent has been signed c. Determine if client has allergic reaction to local anesthesia d. Ascertain if chest x-rays and other tests have been prescribed and completed a. Ease the patient to the floor b. Lift the patient and put him on the bed c. Insert a padded tongue depressor between his jaws d. Restraint patient’s body movement Mr Santos is placed on seizure precaution. Which of the following would be contraindicated? a. Obtain his oral temperature b. Encourage to perform his own personal hygiene c. Allow him to wear his own clothing d. Encourage him to be out of bed Usually, how does the patient behave after his seizure has subsided? a. Most comfortable walking and moving about b. Becomes restless and agitated c. Sleeps for a period of time d. Say he is thirsty and hungry 20. During thoracentesis, which of the following nursing intervention will be most crucial? a. Place patient in a quiet and cool room b. Maintain strict aseptic technique c. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest d. Apply pressure over the puncture site as soon as the needle is withdrawn 18. Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position? a. Low fowler’s b. Side lying c. Modified trendelenburg d. Supine Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions? a. Trendelenburg position b. Supine position c. Dorsal Recumbent position d. Orthopneic position 13. Mr Santos is scheduled for CT SCAN for the next day, noon time. Which of the following is the correct preparation as instructed by the nurse? a. Shampoo hair thoroughly to remove oil and dirt b. No special preparation is needed. Instruct the patient to keep his head still and stead c. Give a cleansing enema and give fluids until 8 AM d. Shave scalp and securely attach electrodes to it 19. 12. 17. 14. To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis? a. Place flat in bed b. Turn on the unaffected side c. Turn on the affected side d. On bed rest 15. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason for another chest x-ray, you will explain: a. To rule out pneumothorax b. To rule out any possible perforation c. To decongest d. To rule out any foreign body Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office. Situation: Mrs. Damian an immediate post op cholecystectomy and choledocholithotomy patient, complained of severe pain at the wound site. 21. 16. Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first? Choledocholithotomy is: a. The removal of the gallbladder b. The removal of the stones in the gallbladder c. The removal of the stones in the
  • 28. common bile duct d. The removal of the stones in the kidney 22. 23. The simplest pain relieving technique is: a. Distraction b. Deep breathing exercise c. Taking aspirin d. Positioning Which of the following statement on pain is TRUE? a. Culture and pain are not associated b. Pain accompanies acute illness c. Patient’s reaction to pain Varies d. Pain produces the same reaction such as groaning and moaning 24. When a client complains of pain, your initial response is: a. Record the description of pain b. Verbally acknowledge the pain c. Refer the complaint to the doctor d. Change to a more comfortable position 28. The client complained of abdominal distention and pain. Your nursing intervention that can alleviate pain is: a. Instruct client to go to sleep and relax b. Advice the client to close the lips and avoid deep breathing and talking c. Offer hot and clear soup d. Turn to sides frequently and avoid too much talking 29. Surgical pain might be minimized by which nursing action in the O.R. a. Skill of surgical team and lesser manipulation b. Appropriate preparation for the scheduled procedure c. Use of modern technology in closing the wound d. Proper positioning and draping of clients 30. Inadequate anesthesia is said to be one of the common cause of pain both in intra and post op patients. If General anesthesia is desired, it will involve loss of consciousness. Which of the following are the 2 general types of GA? a. Epidural and Spinal b. Subarachnoid block and Intravenous c. Inhalation and Regional d. Intravenous and Inhalation In pain assessment, which of the following condition is a more reliable indicator? a. Pain rating scale of 1 to 10 b. Facial expression and gestures c. Physiological responses d. Patients description of the pain sensation 25. alleviate anxiety c. Avoid overdosing to prevent dependence/tolerance d. Monitor VS, more importantly RR Situation: You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pain as you know, is very subjective. 26. 27. 28 A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment reveals bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention would you take? a. Medicate client as prescribed b. Encourage client to do imagery c. Encourage deep breathing and turning d. Call surgeon stat Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will be your priority nursing action? a. Check abdominal dressing for possible swelling b. Explain the proper use of PCA to Situation: Nurse’s attitudes toward the pain influence the way they perceive and interact with clients in pain. 31. Nurses should be aware that older adults are at risk of underrated pain. Nursing assessment and management of pain should address the following beliefs EXCEPT: a. Older patients seldom tend to report pain than the younger ones b. Pain is a sign of weakness c. Older patients do not believe in analgesics, they are tolerant d. Complaining of pain will lead to being labeled a ‘bad’ patient 32. Nurses should understand that when a client responds favorably to a placebo, it is known as the ‘placebo effect’. Placebos do not indicate
  • 29. 29 whether or not a client has: a. Conscience b. Disease c. Real pain d. Drug tolerance 33. 34. 35. You are the nurse in the pain clinic where you have client who has difficulty specifying the location of pain. How can you assist such client? a. The pain is vague b. By charting-it hurts all over c. Identify the absence and presence of pain d. As the client to point to the painful are by just one finger What symptom, more distressing than pain, should the nurse monitor when giving opioids especially among elderly clients who are in pain? a. Forgetfulness b. Drowsiness c. Constipation d. Allergic reactions like pruritis Physical dependence occurs in anyone who takes opiods over a period of time. What do you tell a mother of a ‘dependent’ when asked for advice? a. Start another drug and slowly lessen the opioid dosage b. Indulge in recreational outdoor activities c. Isolate opioid dependent to a restful resort d. Instruct slow tapering of the drug dosage and alleviate physical withdrawal symptoms Situation: The nurse is performing health education activities for Janevi Segovia, a 30 year old Dentist with Insulin dependent diabetes Miletus. 36. Janevi is preparing a mixed dose of insulin. The nurse is satisfied with her performance when she: a. Draw insulin from the vial of clear insulin first b. Draw insulin from the vial of the intermediate acting insulin first c. Fill both syringes with the prescribed insulin dosage then shake the bottle vigorously d. Withdraw the intermediate acting insulin first before withdrawing the short acting insulin first 37. Janevi complains of nausea, vomiting, diaphoresis and headache. Which of the following nursing intervention are you going to carry out first? a. Withhold the client’s next insulin injection b. Test the client’s blood glucose level c. Administer Tylenol as ordered d. Offer fruit juice, gelatine and chicken bouillon 38. Janevi administered regular insulin at 7 A.M and the nurse should instruct Jane to avoid exercising at around: a. 9 to 11 A.M b. Between 8 A.M to 9 A.M c. After 8 hours d. In the afternoon, after taking lunch 39. Janevi was brought at the emergency room after four month because she fainted in her clinic. The nurse should monitor which of the following test to evaluate the overall therapeutic compliance of a diabetic patient? a. Glycosylated hemoglobin b. Ketone levels c. Fasting blood glucose d. Urine glucose level 40. Upon the assessment of Hba1c of Mrs. Segovia, The nurse has been informed of a 9% Hba1c result. In this case, she will teach the patient to: a. Avoid infection b. Prevent and recognize hyperglycaemia c. Take adequate food and nutrition d. Prevent and recognize hypoglycaemia 41. The nurse is teaching plan of care for Jane with regards to proper foot care. Which of the following should be included in the plan? a. Soak feet in hot water b. Avoid using mild soap on the feet c. Apply a moisturizing lotion to dry feet but not between the toes d. Always have a podiatrist to cut your toe nails; never cut them yourself 42. Another patient was brought to the emergency room in an unresponsive state and a diagnosis of hyperglycaemic hyperosmolar nonketotic syndrome is made. The nurse immediately
  • 30. prepares to initiate which of the following anticipated physician’s order? a. Endotracheal intubation b. 100 unites of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate 43. 44. 45. Jane eventually developed DKA and is being treated in the emergency room. Which finding would the nurse expect to note as confirming this diagnosis? a. Comatose state b. Decreased urine output c. Increased respiration and an increase in pH d. Elevated blood glucose level and low plasma bicarbonate level The nurse teaches Jane to know the difference between hypoglycaemia and ketoacidosis. Jane demonstrates understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops? a. Polyuria b. Shakiness c. Blurred Vision d. Fruity breath odour Jane has been scheduled to have a FBS taken in the morning. The nurse tells Jane not to eat or drink after midnight. Prior to taking the blood specimen, the nurse noticed that Jane is holding a bottle of distilled water. The nurse asked Jane if she drink any, and she said “yes.” Which of the following is the best nursing action? a. Administer syrup of ipecac to remove the distilled water from the stomach b. Suction the stomach content using NGT prior to specimen collection c. Advice to physician to reschedule to diagnostic examination next day d. Continue as usual and have the FBS analysis performed and specimen be taken Situation: Elderly clients usually produce unusual signs when it comes to different diseases. The ageing process is a complicated process and the nurse should understand that it is an inevitable fact and she must be prepared to care for the growing elderly population. 46. 30 Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging. a. Ineffective airway clearance b. Decreased alveolar surfaced area c. Decreased anterior-posterior chest diameter d. Hyperventilation 47. The older patient is at higher risk for incontinence because of: a. Dilated urethra b. Increased glomerular filtration rate c. Diuretic use d. Decreased bladder capacity 48. Merle, age 86, is complaining of dizziness when she stands up. This may indicate: a. Dementia b. Functional decline c. A visual problem d. Drug toxicity 49. Cardiac ischemia in an older patient usually produces: a. ST-T wave changes b. Chest pain radiating to the left arm c. Very high creatinine kinase level d. Acute confusion 50. The most dependable sign of infection in the older patient is: a. Change in mental status b. Fever c. Pain d. Decreased breath sounds with crackles Situation – In the OR, there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. 51. Which of the following should be given highest priority when receiving patient in the OR? a. Assess level of consciousness b. Verify patient identification and informed consent c. Assess vital signs d. Check for jewelry, gown, manicure, and dentures 52. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. When are these
  • 31. 31 procedures best scheduled? a. Last case b. In between cases c. According to availability of anaesthesiologist d. According to the surgeon’s preference 53. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure… a. the surgeon greets his client before induction of anesthesia b. the surgeon and anesthesiologist are in tandem c. strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board. d. Client is monitored throughout the surgery by the assistant anesthesiologist The nurse knows that the temperature and time is set to the optimum level to destroy not only the microorganism, but also the spores. Which of the following is the ideal setting of the autoclave machine? a. 10,000 degree Celsius for 1 hour b. 5,000 degree Celsius for 30 minutes c. 37 degree Celsius for 15 minutes d. 121 degree Celsius for 15 minutes 59. Chemical indicators communicate that: a. The items are sterile b. That the items had undergone sterilization process but not necessarily sterile c. The items are disinfected d. That the items had undergone disinfection process but not necessarily disinfected If a nurse will sterilize a heat and moisture labile instruments, It is according to AORN recommendation to use which of the following method of sterilization? a. Ethylene oxide gas b. Autoclaving c. Flash sterilizer d. Alcohol immersion Another nursing check that should not be missed before the induction of general anesthesia is: a. check for presence underwear b. check for presence dentures c. check patient’s ID d. check baseline vital signs 55. It is important that before a nurse prepares the material to be sterilized, a chemical indicator strip should be placed above the package, preferably, Muslin sheet. What is the color of the striped produced after autoclaving? a. Black b. Blue c. Gray d. Purple 60. 54. 58. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for: a. perioperative anxiety and stress b. delayed coagulation time c. delayed wound healing d. postoperative respiratory infection Situation: Sterilization is the process of removing ALL living microorganism. To be free of ALL living microorganism is sterility. 56. There are 3 general types of sterilization use in the hospital, which one is not included? a. Steam sterilization b. Physical sterilization c. Chemical sterilization d. Sterilization by boiling 57. Autoclave or steam under pressure is the most common method of sterilization in the hospital. Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. 61. Which of the following role would be the responsibility of the scrub nurse? a. Assess the readiness of the client prior to surgery b. Ensure that the airway is adequate c. Account for the number of sponges, needles, supplies, used during the surgical procedure. d. Evaluate the type of anesthesia appropriate for the surgical client
  • 32. 62. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic? a. Put side rails up and ask the client not to get out of bed b. Send the client to OR with the family c. Allow client to get up to go to the comfort room d. Obtain consent form 63. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing surgery. If hair at the operative site is not shaved, what should be done to make suturing easy and lessen chance of incision infection? a. Draped b. Pulled c. Clipped d. Shampooed 64. 65. It is also the nurse’s function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection? a. Localized heat and redness b. Serosanguinous exudates and skin blanching c. Separation of the incision d. Blood clots and scar tissue are visible 68. Tess, the PACU nurse, discovered that Malou, who weighs 110 lbs prior to surgery, is in severe pain 3 hrs after cholecystectomy. Upon checking the chart, Malou found out that she has an order of Demerol 100 mg I.M. prn for pain. Tess should verify the order with: a. Nurse Supervisor b. Surgeon c. Anesthesiologist d. Intern on duty 69. Rosie, 57, who is diabetic is for debridement if incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do? a. Double check the doctor’s order and call the attending MD b. Communicate with the ward nurse to verify if insulin was incorporated or not c. Communicate with the client to verify if insulin was incorporated d. Incorporate insulin as ordered. 70. The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patient’s chart? a. Presence of prosthetoid devices such as dentures, artificial limbs hearing aid, etc. b. Baseline physical, emotional, and psychosocial data c. Arguments between nurses and residents regarding treatments d. Observed untoward signs and symptoms and interventions including contaminant intervening factors Which of the following nursing interventions is done when examining the incision wound and changing the dressing? a. Observe the dressing and type and odor of drainage if any b. Get patient’s consent c. Wash hands d. Request the client to expose the incision wound Situation – The preoperative nurse collaborates with the client significant others, and healthcare providers. 66. To control environmental hazards in the OR, the nurse collaborates with the following departments EXCEPT: a. Biomedical division b. Infection control committee c. Chaplaincy services d. Pathology department 67. An air crash occurred near the hospital leading to a surge of trauma patient. One of the last 32 patients will need surgical amputation but there are no sterile surgical equipments. In this case, which of the following will the nurse expect? a. Equipments needed for surgery need not be sterilized if this is an emergency necessitating life saving measures b. Forwarding the trauma client to the nearest hospital that has available sterile equipments is appropriate c. The nurse will need to sterilize the item before using it to the client using the regular sterilization setting at 121 degree Celsius in 15 minutes d. In such cases, flash sterlizer will be use at 132 degree Celsius in 3 minutes
  • 33. 33 Situation – Team efforts is best demonstrated in the OR. 71. 72. 73. 74. 75. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? a. Who is your internist b. Who is your assistant and anaesthesiologist, and what is your preferred time and type of surgery? c. Who are your anaesthesiologist, internist, and assistant d. Who is your anaesthesiologist In the OR, the nursing tandem for every surgery is: a. Instrument technician and circulating nurse b. Nurse anaesthetist, nurse assistant, and instrument technician c. Scrub nurse and nurse anaesthetist d. Scrub and circulating nurses While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team? a. Surgeon, anaesthesiologist, scrub nurse, radiologist, orderly b. Surgeon, assistants, scrub nurse, circulating nurse, anaesthesiologist c. Surgeon, assistant surgeon, anaesthesiologist, scrub nurse, pathologist d. Surgeon, assistant surgeon, anaesthesiologist, intern, scrub nurse Who usually act as an important part of the OR personnel by getting the wheelchair or stretcher, and pushing/pulling them towards the operating room? a. Orderly/clerk b. Nurse Supervisor c. Circulating Nurse d. Anaesthesiologist The breakdown in teamwork is often times a failure in: a. Electricity b. Inadequate supply c. Leg work d. Communication Situation: Basic knowledge on Intravenous solutions is necessary for care of clients with problems with fluids and electrolytes. 76. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure? a. 0.45% sodium chloride b. 0.33% sodium chloride c. Normal saline solution d. Lactated ringer’s solution 77. The physician orders the nurse to prepare an isotonic solution. Which of the following IV solution would the nurse expect the intern to prescribe? a. 5% dextrose in water b. 0.45% sodium chloride c. 10% dextrose in water d. 5% dextrose in 0.9% sodium chloride 78. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that the client’s IV Site is cool, pale and swollen and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client? a. Infection b. Phlebitis c. Infiltration d. Thrombophelibitis 79. A nurse reviews the client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? a. U waves b. Absend P waves c. Elevated T waves d. Elevated ST segment 80. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
  • 34. order? a. b. c. d. 82. 83. An informed consent is required for: a. closed reduction of a fracture b. irrigation of the external ear canal c. insertion of intravenous catheter d. urethral catheterization Which of the following is not true with regards to the informed consent? a. It should describe different treatment alternatives b. It should contain a thorough and detailed explanation of the procedure to be done c. It should describe the client’s diagnosis d. It should give an explanation of the client’s prognosis You know that the hallmark of nursing accountability is the: a. accurate documentation and reporting b. admitting your mistakes c. filing an incidence report d. reporting a medication error 84. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for deficient fluid volume? a. A client with colostomy b. A client with congestive heart failure c. A client with decreased kidney function d. A client receiving frequent wound irrigation As an OR nurse, what are your foremost considerations for selecting chemical agents for disinfection? a. Material compatibility and efficiency b. Odor and availability c. Cost and duration of disinfection process d. Duration of disinfection and efficiency 87. Before you use a disinfected instrument it is essential that you: a. Rinse with tap water followed by alcohol b. Wrap the instrument with sterile water c. Dry the instrument thoroughly d. Rinse with sterile water 88. You have a critical heat labile instrument to sterilize and are considering to use high level disinfectant. What should you do? a. Cover the soaking vessel to contain the vapor b. Double the amount of high level disinfectant c. Test the potency of the high level disinfectant d. Prolong the exposure time according to manufacturer’s direction 89. To achieve sterilization using disinfectants, which of the following is used? a. Low level disinfectants immersion in 24 hours b. Intermediate level disinfectants immersion in 12 hours c. High level disinfectants immersion in 1 hour d. High level disinfectant immersion in 10 hours Bronchoscope, Thermometer, Endoscope, ET tube, Cytoscope are all BEST sterilized using which of the following? a. Autoclaving at 121 degree Celsius in 15 minutes b. Flash sterilizer at 132 degree Celsius in 3 minutes c. Ethylene Oxide gas aeration for 20 hours d. 2% Glutaraldehyde immersion for 10 hours A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines that which client is at risk for excess fluid volume? a. The client taking diuretics b. The client with renal failure c. The client with an ileostomy d. The client who requires gastrointestinal suctioning 85. 86. 90. 81. Any IV solution available to KVO Isotonic solution Hypertonic solution Hypotonic solution Situation: As a perioperative nurse, you are aware of the correct processing methods for preparing instruments and other devices for patient use to prevent infection. 34 Situation: The OR is divided into three zones to control traffic flow and contamination
  • 35. 35 91. 92. 93. What OR attires are worn in the restricted area? a. Scrub suit, OR shoes, head cap b. Head cap, scrub suit, mask, OR shoes c. Mask, OR shoes, scrub suit d. Cap, mask, gloves, shoes Nursing intervention for a patient on low dose IV insulin therapy includes the following, EXCEPT: a. Elevation of serum ketones to monitor ketosis b. Vital signs including BP c. Estimate serum potassium d. Elevation of blood glucose levels The doctor ordered to incorporate 1000”u” insulin to the remaining on-going IV. The strength is 500 /ml. How much should you incorporate into the IV solution? a. 10 ml b. 0.5 ml c. 2 ml d. 5 ml 94. Insulins using insulin syringe are given using how many degrees of needle insertion? a. 45 b. 180 c. 90 d. 15 97. 2 organizations endorsed that sterility are affected by factors other than the time itself, these are: a. The PNA and the PRC b. AORN and JCAHO c. ORNAP and MCNAP d. MMDA and DILG 98. All of these factors affect the sterility of the OR equipments, these are the following except: a. The material used for packaging b. The handling of the materials as well as its transport c. Storage d. The chemical or process used in sterililzing the material 99. When you say sterile, it means: a. The material is clean b. The material as well as the equipments are sterilized and had undergone a rigorous sterilization process c. There is a black stripe on the paper indicator d. The material has no microorganism nor spores present that might cause an infection 100. In using liquid sterilizer versus autoclave machine, which of the following is true? a. Autoclave is better in sterilizing OR supplies versus liquid sterilizer b. They are both capable of sterilizing the equipments, however, it is necessary to soak supplies in the liquid sterilizer for a longer period of time c. Sharps are sterilized using autoclave and not cidex d. If liquid sterilizer is used, rinsing it before using is not necessary Multiple vial-dose-insulin when in use should be a. Kept at room temperature b. Kept in narcotic cabinet c. Kept in the refrigerator d. Store in the freezer 95. process Situation: Maintenance of sterility is an important function a nurse should perform in any OR setting. 96. Which of the following is true with regards to sterility? a. Sterility is time related, items are not considered sterile after a period of 30 days of being not use. b. for 9 months, sterile items are considered sterile as long as they are covered with sterile muslin cover and stored in a dust proof covers. c. Sterility is event related, not time related d. For 3 weeks, items double covered with muslin are considered sterile as long as they have undergone the sterilization
  • 36. d. CT Scan and Incidence report NURSING PRACTICE IV Situation: After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and instrument count. 1. The layer of the abdomen is divided into 5. Arrange the following from the first layer going to the deepest layer: 1. Fascia 2. Muscle 3. Peritoneum 4. Subcutaneous/Fat 5. Skin a. 5,4,3,2,1 b. 5,4,1,3,2 c. 5,4,2,1,3 d. 5,4,1,2,3 6. A client has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity? a. clamp tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine b. drain urine from the drainage bag into the sterile container c. disconnect the tubing from the urinary catheter and let urine flow into a sterile container d. wipe the self-sealing aspiration port with antiseptic solution and insert a sterile needle into the self-sealing port 7. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best? a. Upon waking up, cough deeply and expectorate into container b. Cough after pursed lip breathing c. Save sputum for two days in covered container d. After respiratory treatment, expectorate into a container 8. The best time for collecting the sputum specimen for culture and sensitivity is: a. Before retiring at night b. Anytime of the day c. Upon waking up in the morning d. Before meals 9. When suctioning the endotracheal tube, the nurse should: a. Explain procedure to patient; insert catheter gently applying suction. Withdrawn using twisting motion b. Insert catheter until resistance is met, and then withdraw slightly, applying suction intermittently as catheter is withdrawn c. Hyperoxygenate client insert catheter using back and forth motion d. Insert suction catheter four inches into the tube, suction 30 seconds using Counting is performed thrice: During the preincision phase, the operative phase and closing phase. Who counts the sponges, needles and instruments? a. The scrub nurse only b. The circulating nurse only c. The surgeon and the assistant surgeon d. The scrub nurse and the circulating nurse 2. Situation: An entry level nurse should be able to apply theoretical knowledge in the performance of the basic nursing skills. 3. 4. 5. 36 When is the first sponge/instrument count reported? a. Before closing the subcutaneous layer b. Before peritoneum is closed c. Before closing the skin d. Before the fascia is sutured Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? a. Anaesthesiologists b. Surgeon c. OR nurse supervisor d. Circulating nurse Which of the following are 2 interventions of the surgical team when an instrument was confirmed missing? a. MRI and Incidence report b. CT Scan, MRI, Incidence report c. X-RAY and Incidence report
  • 37. 37 twirling motion as catheter is withdrawn 10. The purpose of NGT IMMEDIATELY after an operation is: a. For feeding or gavage b. For gastric decompression c. For lavage, or the cleansing of the stomach content d. For the rapid return of peristalsis Situation - Mr. Santos, 50, is to undergo cystoscopy due to multiple problems like scantly urination, hematuria and dysuria. Nursing intervention includes: a. Bed rest b. Warm moist soak c. Early ambulation d. Hot sitz bath Situation – Mang Felix, a 79 year old man who is brought to the Surgical Unit from PACU after a transurethral resection. You are assigned to receive him. You noted that he has a 3-way indwelling urinary catheter for continuous fast drip bladder irrigation which is connected to a straight drainage. 16. 11. 12. 13. Immediately after surgery, what would you expect his urine to be? a. Light yellow b. Bright red c. Amber d. Pinkish to red 17. In the OR, you will position Mr. Santos who is cystoscopy in: a. Supine b. Lithotomy c. Semi-fowler d. Trendelenburg The purpose of the continuous bladder irrigation is to: a. Allow continuous monitoring of the fluid output status b. Provide continuous flushing of clots and debris from the bladder c. Allow for proper exchange of electrolytes and fluid d. Ensure accurate monitoring of intake and output 18. After cystoscopy, Mr. Santos asked you to explain why there is no incision of any kind. What do you tell him? a. “Cystoscopy is direct visualization and examination by urologist”. b. “Cystoscopy is done by x-ray visualization of the urinary tract”. c. “Cystoscopy is done by using lasers on the urinary tract”. d. “Cystoscopy is an endoscopic procedure of the urinary tract”. Mang Felix informs you that he feels some discomfort on the hypogastric area and he has to void. What will be your most appropriate action? a. Remove his catheter then allow him to void on his own b. Irrigate his catheter c. Tell him to “Go ahead and void. You have an indwelling catheter.” d. Assess color and rate of outflow, if there is changes refer to urologist for possible irrigation. 19. You decided to check on Mang Felix’s IV fluid infusion. You noted a change in flow rate, pallor and coldness around the insertion site. What is your assessment finding? a. Phlebitis b. Infiltration to subcutaneous tissue c. Pyrogenic reaction d. Air embolism 20. Knowing that proper documentation of You are the nurse in charge in Mr. Santos. When asked what are the organs to be examined during cystoscopy, you will enumerate as follows: a. Urethra, kidney, bladder, urethra b. Urethra, bladder wall, trigone, ureteral opening c. Bladder wall, uterine wall, and urethral opening d. Urethral opening, ureteral opening bladder 14. Within 24-48 hours post cystoscopy, it is normal to observe one the following: a. Pink-tinged urine b. Distended bladder c. Signs of infection d. Prolonged hematuria 15. Leg cramps are NOT uncommon post cystoscopy.
  • 38. assessment findings and interventions are important responsibilities of the nurse during first post-operative day, which of the following is the LEAST relevant to document in the case of Mang Felix? a. Chest pain and vital signs b. Intravenous infusion rate c. Amount, color, and consistency of bladder irrigation drainage d. Activities of daily living started Situation: Melamine contamination in milk has brought worldwide crisis both in the milk production sector as well as the health and economy. Being aware of the current events is one quality that a nurse should possess to prove that nursing is a dynamic profession that will adapt depending on the patient’s needs. 21. Melamine is a synthetic resin used for whiteboards, hard plastics and jewellery box covers due to its fire retardant properties. Milk and food manufacturers add melamine in order to: a. It has a bacteriostatic property leading to increase food and milk life as a way of preserving the foods b. Gives a glazy and more edible look on foods c. Make milks more tasty and creamy d. Create an illusion of a high protein content on their products 22. Which government agency is responsible for testing the melamine content of foods and food products? a. DOH b. MMDA c. NBI d. BFAD 25. 24. 38 Infants are the most vulnerable to melamine poisoning. Which of the following is NOT a sign of melamine poisoning? a. Irritability, Back ache, Urolithiasis b. High blood pressure, fever c. Anuria, Oliguria or Hematuria What kind of renal failure will melamine poisoning cause? a. Chronic, Prerenal b. Chronic, Intrarenal c. Acute, Postrenal d. Acute, Prerenal Situation: Leukemia is the most common type of childhood cancer. Acute Lymphoid Leukemia is the cause of almost 1/3 of all cancer that occurs in children under age 15. 26. The survival rate for Acute Lymphoid Leukemia is approximately: a. 25% b. 40% c. 75% d. 95% 27. Whereas acute nonlymphoid leukemia has a survival rate of: a. 25% b. 40% c. 75% d. 95% 28. The three main consequence of leukemia that cause the most danger is: a. Neutropenia causing infection, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies b. Central nervous system infiltration, anemia causing impaired oxygenation and thrombocytopenia leading to bleeding tendencies c. Splenomegaly, hepatomegaly, fractures d. Invasion by the leukemic cells to the bone causing severe bone pain 29. Gold standard in the diagnosis of leukemia is by which of the following? a. Blood culture and sensitivity b. Bone marrow biopsy c. Blood biopsy d. CSF aspiration and examination 30. Adriamycin,Vincristine,Prednisone and L asparaginase are given to the client for long term therapy. One common side effect, Most of the milks contaminated by Melamine came from which country? a. India b. China c. Philippines d. Korea 23. d. Fever, Irritability and a large output of diluted urine
  • 39. 39 especially of adriamycin is alopecia. The child asks: “Will I get my hair back once again?” The nurse best respond is by saying: a. “Don’t be silly, ofcourse you will get your hair back” b. “We are not sure, let’s hope it’ll grow” c. “This side effect is usually permanent, But I will get the doctor to discuss it for you” d. “Your hair will regrow in 3 to 6 months but of different color, usually darker and of different texture” sensitivity of the breast. 34. Carmen, who is asking the nurse the most appropriate time of the month to do her selfexamination of the breast. The MOST appropriate reply by the nurse would be: a. the 26th day of the menstrual cycle b. 7 to 8 days after conclusion of the menstrual period c. during her menstruation d. the same day each month 35. Carmen being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy? a. Cover the areas with thick clothing materials b. Apply a heating pad to the site c. Wash skin with water after the therapy d. Avoid applying creams and powders to the area 36. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breast cancer that is recommended for developing countries is: a. a monthly breast self-examination (BSE) and an annual health worker breast examination (HWBE) b. an annual hormone receptor assay c. an annual mammogram d. a physician conduct a breast clinical examination every 2 years 37. The purpose of performing the breast selfexamination (BSE) regularly is to discover: a. fibrocystic masses b. areas of thickness or fullness c. cancerous lumps d. changes from previous BSE 38. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE: a. on the same day of each month b. on the first day of her menstruation c. right after the menstrual period d. on the last day of her menstruation 39. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for: a. thickening of the tissue Situation: Breast Cancer is the 2nd most common type of cancer after lung cancer and 99% of which, occurs in woman. Survival rate is 98% if this is detected early and treated promptly. Carmen is a 53 year old patient in the high risk group for breast cancer was recently diagnosed with Breast cancer. 31. 32. 33. All of the following are factors that said to contribute to the development of breast cancer except: a. Prolonged exposure to estrogen such as an early menarche or late menopause, nulliparity and childbirth after age 30 b. Genetics c. Increasing Age d. Prolonged intake of Tamoxifen (Nolvadex) Protective factors for the development of breast cancer includes which of the following except: a. Exercise b. Breast feeding c. Prophylactic Tamoxifen d. Alcohol intake A patient diagnosed with breast cancer has been offered the treatment choices of breast conservation surgery with radiation or a modified radical mastectomy. When questioned by the patient about these options, the nurse informs the patient that the lumpectomy with radiation: a. reduces the fear and anxiety that accompany the diagnosis and treatment of cancer b. has about the same 10-year survival rate as the modified radical mastectomy c. provides a shorter treatment period with a fewer long term complications d. preserves the normal appearance and
  • 40. b. lumps in the breast tissue c. axillary lymphnodes d. change in size and contour 40. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the client’s left shoulder is to: a. bring the breast closer to the examiner’s right hand b. tense the pectoral muscle c. balance the breast tissue more evenly on the chest wall d. facilitate lateral positioning of the breast Situation – Radiation therapy is another modality of cancer management. With emphasis on multidisciplinary management you have important responsibilities as nurse. d. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular, gastrointestinal, renal 45. What intervention should you include in your care plan? a. Inspect his skin for petechiae, bruising, GI bleeding regularly b. Place Albert on strict isolation precaution c. Provide rest in between activities d. Administer antipyretics if his temperature exceeds 38C Situation: Burn are cause by transfer of heat source to the body. It can be thermal, electrical, radiation or chemical. 42. 43. 44. 40 Albert is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions would be most helpful for Albert? a. Tell him that sometimes these feelings can be psychogenic b. Refer him to the physician c. Reassure him that these feelings are normal d. Help him plan his activities Immediately following the radiation teletherapy, Albert is a. Considered radioactive for 24 hrs b. Given a complete bath c. Placed on isolation for 6 hours d. Free from radiation Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should observe the following symptoms: a. Petechiae, ecchymosis, epistaxis b. Weakness, easy fatigability, pallor c. Headache, dizziness, blurred vision d. Severe sore throat, bacteremia, hepatomegaly What nursing diagnosis should be of highest priority? a. Knowledge deficit regarding thrombocytopenia precautions b. Activity intolerance c. Impaired tissue integrity A burn characterized by Pale white appearance, charred or with fat exposed and painlessness is: a. Superficial partial thickness burn b. Deep partial thickness burn c. Full thickness burn d. Deep full thickness burn 47. Which of the following BEST describes superficial partial thickness burn or first degree burn? a. Structures beneath the skin are damage b. Dermis is partially damaged c. Epidermis and dermis are both damaged d. Epidermis is damaged 48. A burn that is said to be “WEEPING” is classified as: a. Superficial partial thickness burn b. Deep partial thickness burn c. Full thickness burn d. Deep full thickness burn 49. During the Acute phase of the burn injury, which of the following is a priority? a. wound healing b. emotional support c. reconstructive surgery d. fluid resuscitation 50. 41. 46. While in the emergent phase, the nurse knows that the priority is to: a. Prevent infection b. Prevent deformities and contractures c. Control pain d. Return the hemodynamic stability via fluid resuscitation
  • 41. 41 51. The MOST effective method of delivering pain medication during the emergent phase is: a. intramuscularly b. orally c. subcutaneously d. intravenously 52. Which of the following can be a fatal complication of upper airway burns? a. stress ulcers b. shock c. hemorrhage d. laryngeal spasms and swelling 58. A 165 lbs trauma client was rushed to the emergency room with full thickness burns on the whole face, right and left arm, and at the anterior upper chest sparing the abdominal area. He also has superficial partial thickness burn at the posterior trunk and at the half upper portion of the left leg. He is at the emergent phase of burn. Using the parkland’s formula, you know that during the first 8 hours of burn, the amount of fluid will be given is: a. 5,400 ml b. 9, 450 ml c. 10,800 ml d. 6,750 ml 59. The doctor incorporated insulin on the client’s fluid during the emergent phase. The nurse knows that insulin is given because: a. Clients with burn also develops Metabolic acidosis b. Clients with burn also develops hyperglycemia c. Insulin is needed for additional energy and glucose burning after the stressful incidence to hasten wound healing, regain of consciousness and rapid return of hemodynamic stability d. For hyperkalemia 60. The IV fluid of choice for burn as well as dehydration is: a. 0.45% NaCl b. Sterile water c. NSS d. D5LR When a client accidentally splashes chemicals to his eyes, The initial priority care following the chemical burn is to: a. irrigate with normal saline for 1 to 15 minutes b. transport to a physician immediately c. irrigate with water for 15 minutes or longer d. cover the eyes with a sterile gauze 53. the client is developing: a. Cerebral hypoxia b. metabolic acidosis c. Hypervolemia d. Renal failure 54. When a client will rush towards you and he has a burning clothes on, It is your priority to do which of the following first? a. log roll on the grass/ground b. slap the flames with his hands c. Try to remove the burning clothes d. Splash the client with 1 bucket of cool water 55. Once the flames are extinguished, it is most important to: a. cover clientwith a warm blanket b. give him sips of water c. calculate the extent of his burns d. assess the Sergio’s breathing 56. 57. During the first 24 hours after the thermal injury, you should asses Sergio for: a. hypokalemia and hypernatremia b. hypokalemia and hyponatremia c. hyperkalemia and hyponatremia d. hyperkalemia and hypernatremia A client who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely indicates that Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 61. You plan to teach Fermin how to irrigate the colostomy when: a. The perineal wound heals And Fermin can sit comfortably on the commode b. Fermin can lie on the side comfortably, about the 3rd postoperative day c. The abdominal incision is closed and
  • 42. contamination is no longer a danger d. The stools starts to become formed, around the 7th postoperative day it is important for nurses to gather as much information to be able to address their needs for nursing care. 66. 62. 63. 64. 65. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure: a. When Fermin would have normal bowel movement b. At least 2 hours before visiting hours c. Prior to breakfast and morning care d. After Fermin accepts alteration in body image When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin: a. Lubricates the tip of the catheter prior to inserting into the stoma b. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion c. Discontinues the insertion of fluid after 500 ml of fluid has been instilled d. Clamps of the flow of fluid when felling uncomfortable You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report: a. If I have any difficulty inserting the irrigating tub into the stoma.” b. If I noticed a loss of sensation to touch in the stoma tissue.” c. The expulsion of flatus while the irrigating fluid is running out.” d. When mucus is passed from the stoma between the irrigations.” You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is important that I eat: a. Soft food that is easily digested and absorbed by my large intestines.” b. Bland food so that my intestines do not become irritated.” c. Food low in fiber so that there are fewer stools.” d. Everything that I ate before the operation, while avoiding foods that cause gas”. Critically ill patients frequently complain about which of the following when hospitalized? a. Hospital food b. Lack of privacy c. Lack of blankets d. Inadequate nursing staff 67. Who of the following is at greatest risk of developing sensory problem? a. Female patient b. Transplant patient c. Adoloscent d. Unresponsive patient 68. Which of the following factors may inhibit learning in critically ill patients? a. Gender b. Educational level c. Medication d. Previous knowledge of illness 69. Which of the following statements does not apply to critically ill patients? a. Majority need extensive rehabilitation b. All have been hospitalized previously c. Are physically unstable d. Most have chronic illness 70. Families of critically ill patients desire which of the following needs to be met first by the nurse? a. Provision of comfortable space b. Emotional support c. Updated information on client’s status d. Spiritual counselling Situation: Johnny, sought consultation to the hospital because of fatigability, irritability, jittery and he has been experiencing this sign and symptoms for the past 5 months. 42 His diagnosis was hyperthyroidism, the following are expected symptoms except: a. Anorexia b. Fine tremors of the hand c. Palpitation d. Hyper alertness 72. Situation: Based on studies of nurses working in special units like the intensive care unit and coronary care unit, 71. She has to take drugs to treat her hyperthyroidism. Which of the following will you NOT expect that the doctor will prescribe?
  • 43. 43 a. b. c. d. 73. 74. 75. Colace (Docusate) Tapazole (Methimazole) Cytomel (Liothyronine) Synthroid (Levothyroxine) The nurse knows that Tapazole has which of the following side effect that will warrant immediate withholding of the medication? a. Death b. Hyperthermia c. Sore throat d. Thrombocytosis You asked questions as soon as she regained consciousness from thyroidectomy primarily to assess the evidence of: a. Thyroid storm b. Damage to the laryngeal nerve c. Mediastinal shift d. Hypocalcaemia tetany Should you check for haemorrhage, you will: a. Slip your hand under the nape of her neck b. Check for hypotension c. Apply neck collar to prevent haemorrhage d. Observe the dressing if it is soaked with blood to: a. Decrease the vascularity and size of the thyroid gland b. Decrease the size of the thyroid gland only c. Increase the vascularity and size of the thyroid gland d. Increase the size of the thyroid gland only 79. Which of the following is a side effect of Lugol’s solution? a. Hypokalemia b. Enlargement of the Thryoid gland c. Nystagmus d. Excessive salivation 80. In administering Lugol’s solution, the precautionary measure should include: a. Administer with glass only b. Dilute with juice and administer with a straw c. Administer it with milk and drink it d. Follow it with milk of magnesia Situation: Pharmacological treatment was not effective for Johnny’s hyperthyroidism and now, he is scheduled for Thyroidectomy. 81. 76. 77. The BMR is based on the measurement that: a. Rate of respiration under different condition of activities and rest b. Amount of oxygen consumption under resting condition over a measured period of time c. Amount of oxygen consumption under stressed condition over a measured period of time d. Ratio of respiration to pulse rate over a measured period of time Instruments in the surgical suite for surgery is classified as either CRITICAL, SEMI CRITICAL and NON CRITICAL. If the instrument are introduced directly into the blood stream or into any normally sterile cavity or area of the body it is classified as: a. Critical b. Non Critical c. Semi Critical d. Ultra Critical 82. Instruments that do not touch the patient or have contact only to intact skin is classified as: a. Critical b. Non Critical c. Semi Critical d. Ultra Critical 83. If an instrument is classified as Semi Critical, an acceptable method of making the instrument ready for surgery is through: a. Sterilization b. Disinfection c. Decontamination Basal Metabolic rate is assessed on Johnny to determine his metabolic rate. In assessing the BMR using the standard procedure, you need to tell Johnny that: a. Obstructing his vision b. Restraining his upper and lower extremities c. Obstructing his hearing d. Obstructing his nostrils with a clamp 78. Her physician ordered lugol’s solution in order
  • 44. d. Cleaning 84. While critical items and should be: a. Clean b. Sterilized c. Decontaminated d. Disinfected 85. As a nurse, you know that intact skin acts as an effective barrier to most microorganisms. Therefore, items that come in contact with the intact skin or mucus membranes should be: a. Disinfected b. Clean c. Sterile d. Alcoholized d. Tetany 90. After surgery Johnny develops peripheral numbness, tingling and muscle twitching and spasm. What would you anticipate to administer? a. Magnesium sulfate b. Potassium iodide c. Calcium gluconate d. Potassium chloride Situation: Budgeting is an important part of a nurse managerial activity. The correct allocation and distribution of resources is vital in the harmonious operation of the financial balance of the agency. 91. 86. You are caring for Johnny who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Johnny to: a. Perform range and motion exercise on the head and neck b. Apply gentle pressure against the incision when swallowing c. Cough and deep breathe every 2 hours d. Support head with the hands when changing position 87. Which of the following nursing interventions is appropriate after a total thyroidectomy? a. Place pillows under your patient’s shoulders. b. Raise the knee-gatch to 30 degrees c. Keep you patient in a high-fowler’s position. d. Support the patient’s head and neck with pillows and sandbags. 92. Which of the following best defines Capital Budget? a. Budget to estimate the cost of direct labour, number of staff to be hired and necessary number of workers to meet the general patient needs b. Includes the monthly and daily expenses and expected revenue and expenses c. These are related to long term planning and includes major replacement or expansion of the plant, major equipment and inventories. d. These are expenses that are not dependent on the level of production or sales. They tend to be time-related, such as salaries or rents being paid per month 93. Which of the following best described Operational Budget? a. Budget to estimate the cost of direct labour, number of staff to be hired and necessary number of workers to meet the general patient needs b. Includes the monthly and daily expenses and expected revenue and expenses c. These are related to long term planning and includes major replacement or As Johnny’s nurse, you plan to set up emergency equipment at her bedside following thyroidectomy. You should include: a. An airway and rebreathing tube b. A tracheostomy set and oxygen c. A crush cart with bed board d. Two ampules of sodium bicarbonate 88. Which of the following best defines Budget? a. Plan for the allocation of resources for future use b. The process of allocating resources for future use c. Estimate cost of expenses d. Continuous process in seeing that the goals and objective of the agency is met 89. 44 If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develops postoperatively? a. Cardiac arrest b. Respiratory failure c. Dyspnea
  • 45. 45 expansion of the plant, major equipments and inventories. d. These are expenses that are not dependent on the level of production or sales. They tend to be time-related, such as rent 94. 95. Which of the following accurately describes a Fixed Cost in budgeting? a. These are usually the raw materials and labour salaries that depend on the production or sales b. These are expenses that change in proportion to the activity of a business c. These are expenses that are not dependent on the level of production or sales. They tend to be time-related, such as rent d. This is the summation of the Variable Cost and the Fixed Cost Which of the following accurately describes Variable Cost in budgeting? a. These are related to long term planning and include major replacement or expansion of the plant, major equipments and inventories. b. These are expenses that change in proportion to the activity of a business c. These are expenses that are not dependent on the level of production or sales. They tend to be time-related, such as rent d. This is the summation of the Variable Cost and the Fixed Cost Situation – Andrea is admitted to the ER following an assault where she was hit in the face and head. She was brought to the ER by a police woman. Emergency measures were started. 96. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as: a. Biot’s b. Cheyne stokes c. Kussmaul’s d. Eupnea 97. What do you call the triad of sign and symptoms seen in a client with increasing ICP? a. Virchow’s Triad b. Cushing’s Triad c. The Chinese Triad d. Charcot’s Triad 98. Which of the following is true with the Triad seen in head injuries? a. Narrowing of Pulse pressure, Cheyne stokes respiration, Tachycardia b. Widening Pulse pressure, Irregular respiration, Bradycardia c. Hypertension, Kussmaul’s respiration, Tachycardia d. Hypotension, Irregular respiration, Bradycardia 99. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis? a. Ineffective airway clearance b. Impaired gas exchange c. Ineffective breathing pattern d. Activity intolerance 100. You know the apnea is seen in client’s with cheyne stokes respiration, APNEA is defined as: a. Inability to breathe in a supine position so the patient sits up in bed to breathe b. The patient is dead, the breathing stops c. There is an absence of breathing for a period of time, usually 15 seconds or more d. A period of hypercapnea and hypoxia due to the cessation of respiratory effort inspite of normal respiratory functioning
  • 46. NURSING PRACTICE V Situation: Understanding different models of care is a necessary part of the nurse patient relationship. 1. The focus of this therapy is to have a positive environmental manipulation, physical and social to effect a positive change. A. Milieu B. Psychotherapy C. Behaviour D. Group 2. The client asks the nurse about Milieu therapy. The nurse responds knowing that the primary focus of milieu therapy can be best described by which of the following? A. A form of behavior modification therapy B. A cognitive approach of changing the behaviour C. A living, learning or working environment D. A behavioural approach to changing behaviour 3. A nurse is caring for a client with phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobic object while in relaxed state. The nurse understands that this form of behaviour modification can be best described as: A. Systematic desensitization B. Self-control therapy C. Aversion Therapy D. Operant conditioning 4. A client with major depression is considering cognitive therapy. The client say to the nurse, “How does this treatment works?” The nurse responds by telling the client that: A. “This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties” B. “This type of treatment helps you examine how your past life has contributed to your problems.” C. “This type of treatment helps you to confront your fears by exposing you to the feared object abruptly. D. “This type of treatment will help you relax and develop new coping skills.” 46 5. A Client state, “I get down on myself when I make mistake.” Using Cognitive therapy approach, the nurse should: A. Teach the client relaxation exercise to diminish stress B. Provide the client with Mastery experience to boost self esteem C. Explore the client’s past experiences that causes the illness D. Help client modify the belief that anything less than perfect is horrible 6. The most advantageous therapy for a preschool age child with a history of physical and sexual abuse would be: A. Play B. Psychoanalysis C. Group D. Family 7. An 18 year old client is admitted with the diagnosis of anorexia nervosa. A cognitive behavioural approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to: A. Help the client identify and examine dysfunctional thoughts and beliefs B. Emphasize social interaction with clients who withdraw C. Provide a supportive environment and a therapeutic community D. Examine intrapsychic conflicts and past events in life 8. The nurse is preparing to provide reminiscence therapy for a group of clients. Which of the following clients will the nurse select for this group? A. A client who experiences profound depression with moderate cognitive impairment B. A catatonic, immobile client with moderate cognitive impairment C. An undifferentiated schizophrenic client with moderate cognitive impairment D. A client with mild depression who exhibits who demonstrates normal cognition 9. Which intervention would be typical of a nurse using cognitive-behavioral approach to a client experiencing low self-esteem?
  • 47. 47 A. B. C. D. Use of unconditional positive regard Analysis of free association Classical conditioning Examination of negative thought patterns 10. Which of the following therapies has been strongly advocated for the treatment of posttraumatic stress disorders? A. ECT B. Group Therapy C. Hypnotherapy D. Psychoanalysis 11. The nurse knows that in group therapy, the maximum number of members to include is: A. 4 B. 8 C. 10 D. 16 12. The nurse is providing information to a client with the use of disulfiram (antabuse) for the treatment of alcohol abuse. The nurse understands that this form of therapy works on what principle? A. Negative Reinforcement B. Operant Conditioning C. Aversion Therapy D. Gestalt therapy 13. A biological or medical approach in treating psychiatric patient is: A. Million therapy B. Behavioral therapy C. Somatic therapy D. Psychotherapy 14. Which of these nursing actions belong to the secondary level of preventive intervention? A. Providing mental health consultation to health care providers B. Providing emergency psychiatric services C. Being politically active in relation to mental health issues D. Providing mental health education to members of the community 15. When the nurse identifies a client who has attempted to commit suicide the nurse should: A. call a priest B. counsel the client C. refer the client to the psychiatrist D. refer the matter to the police Situation: Rose seeks psychiatric consultation because of intense fear of flying in an airplane which has greatly affected her chances of success in her job. 16. The most common defense mechanism used by phobic clients is: A. Supression B. Denial C. Rationalization D. Displacement 17. The goal of the therapy in phobia is: A. Change her lifestyle B. Ignore tension producing situation C. Change her reaction towards anxiety D. Eliminate fear producing situations 18. The therapy most effective for client’s with phobia is: A. Hypnotherapy B. Cognitive therapy C. Group therapy D. Behavior therapy 19. The fear and anxiety related to phobia is said to be abruptly decreased when the patient is exposed to what is feared through: A. Guided Imagery B. Systematic desensitization C. Flooding D. Hypotherapy 20. Based on the presence of symptom, the appropriate nursing diagnosis is: A. Self-esteem disturbance B. Activity intolerance C. Impaired adjustment D. Ineffective individual coping Situation: Mang Jose, 39 year old farmer, unmarried, had been confined in the National center for mental health for three years with a diagnosis of schizophrenia. 21. The most common defense mechanism used by a paranoid client is: A. Displacement B. Rationalization C. Suppression D. Projection
  • 48. 22. When Mang Jose says to you: “The voices are telling me bad things again!” The best response is: A. “Whose voices are those?” B. “I doubt what the voices are telling you” C. “I do not hear the voice you say you hear” D. “Are you sure you hear these voices?” 23. A relevant nursing diagnosis for clients with auditory hallucination is: A. Sensory perceptual alteration B. Altered thought process C. Impaired social interaction D. Impaired verbal communication 24. During mealtime, Jose refused to eat telling that the food was poisoned. The nurse should: A. Ignore his remark B. Offer him food in his own container C. Show him how irrational his thinking is D. Respect his refusal to eat 25. When communicating with Jose, The nurse considers the following except: A. Be warm and enthusiastic B. Refrain from touching Jose C. Do not argue regarding his hallucination and delusion D. Use simple, clear language Situation: Gringo seeks psychiatric counselling for his ritualistic behavior of counting his money as many as 10 times before leaving home. 26. An initial appropriate nursing diagnosis is: A. Impaired social interaction B. Ineffective individual coping C. Impaired adjustment D. Anxiety Moderate 27. Obsessive compulsive disorder is BEST described by: A. Uncontrollable impulse to perform an act or ritual repeatedly B. Persistent thoughts C. Recurring unwanted and disturbing thought alternating with a behavior D. Pathological persistence of unwilled thought, feeling or impulse 28. The defense mechanism used by persons with obsessive compulsive disorder is undoing and it 48 is best described in one of the following statements: A. Unacceptable feelings or behavior are kept out of awareness by developing the opposite behavior or emotion B. Consciously unacceptable instinctual drives are diverted into personally and socially acceptable channels C. Something unacceptable already done is symbolically acted out in reverse D. Transfer of emotions associated with a particular person, object or situation to another less threatening person, object or situation 29. To be more effective, the nurse who cares for persons with obsessive compulsive disorder must possess one of the following qualities: A. Compassion B. Patience C. Consistency D. Friendliness 30. Persons with OCD usually manifest: A. Fear B. Apathy C. Suspiciousness D. Anxiety Situation: The patient who is depressed will undergo electroconvulsive therapy. 31. Studies on biological depression support electroconvulsive therapy as a mode of treatment. The rationale is: A. ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding the development of psychotic condition B. The treatment serves as a symbolic punishment for the client who feels guilty and worthless C. ECT relieves depression psychologically by increasing the norepinephrine level D. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defences to deal with this attack. 32. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for: A. electroencephalogram
  • 49. 49 B. general anesthesia C. X-ray D. electrocardiogram 33. Which of the following is a possible side effect which you will discuss with the patient? A. hemorrhage within the brain B. encephalitis C. robot-like body stiffness D. confusion, disorientation and short term memory loss 34. Informed consent is necessary for the treatment for involuntary clients. When this cannot be obtained, permission may be taken from the: A. social worker B. next of kin or guardian C. doctor D. chief nurse 35. After ECT, the nurse should do this action before giving the client fluids, food or medication: A. assess the gag reflex B. next of kin or guardian C. assess the sensorium D. check O2 Sat with a pulse oximeter Situation: Mrs Ethel Agustin 50 y/o, teacher is afflicted with myasthenia gravis. 36. Looking at Mrs Agustin, your assessment would include the following except; A. Nystagmus B. Difficulty of hearing C. Weakness of the levator palpebrae D. Weakness of the ocular muscle 37. In an effort to combat complications which might occur relatives should he taught; A. Checking cardiac rate B. Taking blood pressure reading C. Techniques of oxygen inhalation D. Administration of oxygen inhalation 38. The drug of choice for her condition is; A. Prostigmine B. Morphine C. Codeine D. Prednisone 39. As her nurse, you have to be cautious about administration of medication, if she is under medicated this can cause; A. B. C. D. Emotional crisis Cholinergic crisis Menopausal crisis Myasthenia crisis 40. If you are not extra careful and by chance you give over medication, this would lead to; A. Cholinergic crisis B. Menopausal crisis C. Emotional crisis D. Myasthenia crisis Situation: Rosanna 20 y/o unmarried patient believes that the toilet for the female patient in contaminated with AIDS virus and refuses to use it unless she flushes it three times and wipes the seat same number of times with antiseptic solution. 41. The fear of using “contaminated” toilet seat can be attributed to Rosanna’s inability to; A. Adjust to a strange environment B. Express her anxiety C. Develop the sense of trust in other person D. Control unacceptable impulses or feelings 42. Assessment data upon admission help the nurse to identify this appropriate nursing diagnosis A. Ineffective denial B. Impaired adjustment C. Ineffective individual coping D. Impaired social interaction 43. An effective nursing intervention to help Rosana is; A. Convincing her to use the toilet after the nurse has used it first B. Explaining to her that AIDS cannot be transmitted by using the toilet C. Allowing her to flush and clear the toilet seat until she can manage her anxiety D. Explaining to her how AIDS is transmitted 44. The goal for treatment for Rosana must be directed toward helping her to; A. Walk freely about her past experience B. Develop trusting relationship with others C. Gain insight that her behaviour is due to feeling of anxiety D. Accept the environment unconditionally
  • 50. 45. Psychotherapy which is prescribed for Rosana is described as; A. Establishing an environment adapted to an individual patient needs B. Sustained interaction between the therapist and client to help her develop more functional behaviour C. Using dramatic techniques to portray interpersonal conflicts D. Biologic treatment for mental disorder Situation: Dennis 40 y/o married man, an electrical engineer was admitted with the diagnosis of paranoid disorders. He has become suspicious and distrustful 2 months before admission. Upon admission, he kept on saying, “my wife has been planning to kill me.” 46. A paranoid individual who cannot accept the guilt demonstrate one of the following defense mechanism; A. Denial B. Projection C. Rationalization D. Displacement 47. One morning, Dennis was seen tilting his head as if he was listening to someone. An appropriate nursing intervention would be; A. Tell him to socialize with other patient to divert his attention B. Involve him in group activities C. Address him by name to ask if he is hearing voices again D. Request for an order of antipsychotic medicine B. Self-esteem disturbance C. Ineffective individual coping D. Defensive coping 50. Most appropriate nursing intervention for a client with suspicious behavior is one of the following; A. Talk to the client constantly to reinforce reality B. Involve him in competitive activities C. Use Non Judgmental and Consistent approach D. Project cheerfulness in interacting with the patient Situation: Clients with Bipolar disorder receives a very high nursing attention due to the increasing rate of suicide related to the illness. 51. The nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do? A. Search the client's belongings and room carefully for items that could be used to attempt suicide. B. Express trust that the client won't cause self-harm while in the facility. C. Respect the client's privacy by not searching any belongings. D. Remind all staff members to check on the client frequently. 48. When he says, “these voices are telling me my wife is going to kill me.” A therapeutic communication of the nurse is which one of the following; A. “i do not hear the voices you say you hear” B. “are you really sure you heard those voices?” C. “I do not think you heard those voices?” D. “Whose voices are those?” 49. The nurse confirms that Dennis is manifesting auditory hallucination. The appropriate nursing diagnosis she identifiesis; A. Sensory perceptual alteration 50 52. In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plan is best? A. Provide an activity that is quiet and solitary to avoid increased fatigue such as working on a puzzle and reading a book. B. Plan nothing until the client asks to participate in the milieu C. Offer the client a menu of daily activities and ask the client to participate in all of them D. Provide a structured daily program of activities and encourage the client to participate 53. A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most
  • 51. 51 importantly devises a plan of care that deals specifically with the clients: A. Disturbed thought process B. Imbalanced nutrition C. Self-Care Deficit D. Deficient Knowledge 54. The client is taking a Tricyclic anti-depressant, which of the following is an example of TCA? A. Paxil B. Nardil C. Zoloft D. Pamelor 55. A client visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse suspects: A. cyclothymic disorder. B. Bipolar disorder C. major depression. D. dysthymic disorder. 56. The nurse is planning activities for a client who has bipolar disorder, which aggressive social behaviour. Which of the following activities would be most appropriate for this client? A. Ping Pong B. Linen delivery C. Chess D. Basketball 57. The nurse assesses a client with admitted diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse’s immediate intervention is the client’s: A. Outlandish behaviour and inappropriate dress B. Grandiose delusion of being a royal descendant of king arthut C. Nonstop physical activity and poor nutritional intake D. Constant incessant talking that includes sexual topics and teasing the staff 58. A nurse is conducting a group therapy session and during the session, A client with mania consistently talks and dominates the group. The behaviour is disrupting the group interaction. The nurse would initially: A. Ask the client to leave the group session B. Tell the client that she will not be allowed to attend any more group sessions C. Tell the client that she needs to allow other client in a group time to talk D. Ask another nurse to escort the client out of the group session 59. A professional artist is admitted to the psychiatric unit for treatment of bipolar disorder. During the last 2 weeks, the client has created 154 paintings, slept only 2 to 3 hours every 2 days, and lost 18 lb (8.2 kg). Based on Maslow's hierarchy of needs, what should the nurse provide this client with first? A. The opportunity to explore family dynamics B. Help with re-establishing a normal sleep pattern C. Experiences that build self-esteem D. Art materials and equipment 60. The physician orders lithium carbonate (Lithonate) for a client who's in the manic phase of bipolar disorder. During lithium therapy, the nurse should watch for which adverse reactions? A. Anxiety, restlessness, and sleep disturbance B. Nausea, diarrhea, tremor, and lethargy C. Constipation, lethargy, and ataxia D. Weakness, tremor, and urine retention Situation – Annie has a morbid fear of heights. She asks the nurse what desensitization therapy is: 61. The accurate information of the nurse of the goal of desensitization is: A. To help the clients relax and progressively work up a list of anxiety provoking situations through imagery. B. To provide corrective emotional experiences through a one-to-one intensive relationship. C. To help clients in a group therapy setting to take on specific roles and reenact in front of an audience, situations in which interpersonal conflict is involved. D. To help clients cope with their problems by learning behaviors that are more functional and be better equipped to face reality and make decisions.
  • 52. 62. It is essential in desensitization for the patient to: A. Have rapport with the therapist B. Use deep breathing or another relaxation technique C. Assess one’s self for the need of an anxiolytic drug D. Work through unresolved unconscious conflicts 63. In this level of anxiety, cognitive capacity diminishes. Focus becomes limited and client experiences tunnel vision. Physical signs of anxiety become more pronounced. A. Severe anxiety B. Mild anxiety C. Panic D. Moderate anxiety 64. Antianxiety medications should be used with extreme caution because long term use can lead to: A. Parkinsonian like syndrome B. Hepatic failure C. Hypertensive crisis D. Risk of addiction 65. The nursing management of anxiety related with post-traumatic stress disorder includes all of the following EXCEPT: A. Encourage participation in recreation or sports activities B. Reassure client’s safety while touching client C. Speak in a calm soothing voice D. Remain with the client while fear level is high SITUATION: You are fortunate to be chosen as part of the research team in the hospital. A review of the following IMPORTANT nursing concepts was made. 66. As a professional, a nurse can do research for varied reason except: A. Professional advancement through research participation B. To validate results of new nursing modalities C. For financial gains D. To improve nursing care 67. Each nurse participants was asked to identify a 52 problem. After the identification of the research problem, which of the following should be done? A. Methodology B. Acknowledgement C. Review of related literature D. Formulate hypothesis 68. Which of the following communicate the results of the research to the readers. They facilitate the description of the data. A. Hypothesis B. Research problem C. Statistics D. Tables and Graphs 69. In Quantitative date, which of the following is described as the distance in the scoring unites of the variable from the highest to the lower? A. Frequency B. Median C. Mean D. Range 70. This expresses the variability of the data in reference to the mean. It provides as with a numerical estimate of how far, on the average the separate observation are from the mean: A. Mode B. Median C. Standard deviation D. Frequency Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population. 71. According to the WHO statistics on the Homeless population around the world, which of the following groups of people in the world disproportionately represents the homeless population? A. Hispanics B. Asians C. African Americans D. Caucasians 72. All but one of the following is not a measure of Central Tendency: A. Mode B. Standard Deviation C. Variance D. Range
  • 53. 53 73. In the value: 87, 85, 88, 92, 90; what is the mean? A. 88.2 B. 88.4 C. 87 D. 90 A. There is a control group B. There is an experimental group C. Selection of subjects in the control group is randomized D. There is a careful selection of subjects in the experimental group 74. In the value: 80, 80, 80, 82, 82, 90, 90, 100; what is the mode? A. 80 B. 82 C. 90 D. 85.5 75. In the value: 80, 80, 10, 10, 25, 65, 100, 200; what is the median? A. 71.25 B. 22.5 C. 10 and 25 D. 72.5 80. The researcher implemented a medication regimen using a new type of combination drugs to manic patients while another group of manic patient receives the routine drugs. The researcher however handpicked the experimental group for they are the clients with multiple episodes of bipolar disorder. The researcher utilized which research design? A. Quasi-experimental B. Phenomenological C. Pure experimental D. Longitudinal 76. Draw Lots, Lottery, Table of random numbers or a sampling that ensures that each element of the population has an equal and independent chance of being chosen is called: A. Cluster B. Stratified C. Simple D. Systematic Situation 19: As a nurse, you are expected to participate in initiating or participating in the conduct of research studies to improve nursing practice. You to be updated on the latest trends and issues affected the profession and the best practices arrived at by the profession. 77. An investigator wants to determine some of the problems that are experienced by diabetic clients when using an insulin pump. The investigator went into a clinic where he personally knows several diabetic clients having problem with insulin pump. The type of sampling done by the investigator is called: A. Probability B. Snowball C. Purposive D. Incidental 78. If the researcher implemented a new structured counselling program with a randomized group of subject and a routine counselling program with another randomized group of subject, the research is utilizing which design? A. Quasi experimental B. Comparative C. Experimental D. Methodological 79. Which of the following is not true about a Pure Experimental research? 81. You are interested to study the effects of mediation and relaxation on the pain experienced by cancer patients. What type of variable is pain? A. Dependent B. Independent C. Correlational D. Demographic 82. You would like to compare the support system of patient with chronic illness to those with acute illness. How will you best state your problem? A. A descriptive study to compare the support system of patients with chronic illness and those with acute illness in terms of demographic data and knowledge about intervention. B. The effects of the types of support system of patients with chronic illness and those with acute illness. C. A comparative analysis of the support system of patients with chronic illness and those with acute illness. D. A study to compare the support system of patients with chronic illness and those with acute illness.
  • 54. E. What are the differences of the support system being received by patient with chronic illness and patients with acute illness? 83. You would like to compare the support system of patients with chronic illness to those with acute illness. Considering that the hypothesis was: “Client’s with chronic illness have lesser support system than client’s with acute illness.” What type of research is this? A. Descriptive B. Correlational, Non experimental C. Experimental D. Quasi Experimental 84. In any research study where individual persons are involved, it is important that an informed consent of the study is obtained. The following are essential information about the consent that you should disclose to the prospective subjects except: A. Consent to incomplete disclosure B. Description of benefits, risks and discomforts C. Explanation of procedure D. Assurance of anonymity and confidentiality 85. In the Hypothesis: “The utilization of technology in teaching improves the retention and attention of the nursing students.” Which is the dependent variable? A. Utilization of technology B. Improvement in the retention and attention C. Nursing students D. Teaching Situation: You are actively practicing nurse who has just finished you graduate studies. You learned the value of research and would like to utilize the knowledge and skills gained in the application of research to the nursing service. The following questions apply to research. 86. Which type of research inquiry investigates the issues of human complexity (e.g understanding the human expertise)? A. Logical position B. Positivism C. Naturalistic inquiry D. Quantitative research 54 87. Which of the following studies is based on quantitative research? A. A study examining the bereavement process in spouse of clients with terminal cancer B. A study exploring the factors influencing weight control behaviour C. A Study measuring the effects of sleep deprivation on wound healing D. A study examining client’s feelings before, during and after bone marrow aspiration. 88. Which of the following studies is based on the qualitative research? A. A study examining clients’ reaction to stress after open heart surgery B. A study measuring nutrition and weight loss/gain in clients with cancer C. A study examining oxygen levels after endotracheal suctioning D. A study measuring differences in blood pressure before, during and after procedure 89. An 85 year old client in a nursing home tells a nurse, “I signed the papers of that research study because the doctor was so insistent and I want him to continue taking care for me” Which client right is being violated? A. Right of self determination B. Right to full disclosure C. Right to privacy and confidentiality D. Right not to be harmed 90. A supposition or system of ideas that is proposed to explain a given phenomenon best defines: A. A paradigm B. A theory C. A Concept D. A conceptual framework Situation: Mastery of research design determination is essential in passing the NLE. 91. Ana wants to know if the length of time she will study for the board examination is proportional to her board rating. During the June 2008 board examination, she studied for 6 months and gained 68%, On the next board exam, she studied for 6 months again for a total of 1 year and gained 74%, On the third board exam, She studied for 6 months for a total of 1 and a half
  • 55. 55 year and gained 82%. The research design she used is: A. Comparative B. Experimental C. Correlational D. Qualitative 92. Anton was always eating high fat diet. You want to determine if what will be the effect of high cholesterol food to Anton in the next 10 years. You will use: A. Comparative B. Historical C. Correlational D. Longitudinal 93. Community A was selected randomly as well as community B, nurse Edna conducted teaching to community A and assess if community A will have a better status than community B. This is an example of: A. Comparative B. Experimental C. Correlational D. Qualitative 94. Ana researched on the development of a new way to measure intelligence by creating a 100 item questionnaire that will assess the cognitive skills of an individual. The design best suited for this study is: A. Historical B. Survey C. Methodological D. Case study 95. Gen is conducting a research study on how mark, an AIDS client lives his life. A design suited for this is: A. Historical B. Phenomenological C. Case Study D. Ethnographic 96. Marco is to perform a study about how nurses perform surgical asepsis during World War II. A design best for this study is: A. Historical B. Phenomenological C. Case Study D. Ethnographic 97. Tonyo conducts sampling at barangay 412. He collected 100 random individuals and determine who is their favourite comedian actor. 50% said Dolphy, 20% said Vic Sotto, while some answered Joey de Leon, Allan K, Michael V. Tonyo conducted what type of research study? A. Phenomenological B. Non experimental C. Case Study D. Survey 98. Jane visited a tribe located somewhere in China, it is called the Shin Jea tribe. She studied the way of life, tradition and the societal structure of these people. Jane will best use which research design? A. Historical B. Phenomenological C. Case Study D. Ethnographic 99. Anjoe researched on TB. Its transmission, Causative agent and factors, treatment sign and symptoms as well as medication and all other in depth information about tuberculosis. This study is best suited for which research design? A. Historical B. Phenomenological C. Case Study D. Ethnographic 100. Diana is to conduct a study about the relationship of the number of family members in the household and the electricity bill. Which of the following is the best research design suited for this study? 1. Descriptive 2. Exploratory 3. Explanatory 4. Correlational 5. Comparative 6. Experimental A. 1,4 B. 2,5 C. 3,6 D. 1,5 E. 2,4
  • 56. TEST I - Foundation of Professional Nursing Practice 1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is: a. The physician’s orders. b. The action of a clinical nurse specialist who is recognized expert in the field. c. The statement in the drug literature about administration of terbutaline. d. The actions of a reasonably prudent nurse with similar education and experience. 2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in halfnormal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? a. I.V b. I.M c. Oral d. S.C 3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the medication administration record? a. “Digoxin .1250 mg P.O. once daily” b. “Digoxin 0.1250 mg P.O. once daily” c. “Digoxin 0.125 mg P.O. once daily” d. “Digoxin .125 mg P.O. once daily” 4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority? a. Ineffective peripheral tissue perfusion related to venous congestion. b. Risk for injury related to edema. c. Excess fluid volume related to peripheral vascular disease. d. Impaired gas exchange related to increased blood flow. 56 5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after endorsement? a. A 34 year-old post-operative appendectomy client of five hours who is complaining of pain. b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea. c. A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post operative’s abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care plan should include: a. Assess temperature frequently. b. Provide diversional activities. c. Check circulation every 15-30 minutes. d. Socialize with other patients once a shift. 7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse Incharge knows the purpose of this therapy is to: a. Prevent stress ulcer b. Block prostaglandin synthesis c. Facilitate protein synthesis. d. Enhance gas exchange 8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take? a. Increase the I.V. fluid infusion rate b. Irrigate the indwelling urinary catheter c. Notify the physician d. Continue to monitor and record hourly urine output 9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests that ice application has been effective? a. “My ankle looks less swollen now”. b. “My ankle feels warm”. c. “My ankle appears redder now”.
  • 57. 57 d. “I need something stronger for pain relief” 10. The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia 11. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? a. Have condescending trust and confidence in their subordinates. b. Gives economic and ego awards. c. Communicates downward to staffs. d. Allows decision making among subordinates. 12. Nurse Amy is aware that the following is true about functional nursing a. Provides continuous, coordinated and comprehensive nursing services. b. One-to-one nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrates on tasks and activities. 13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" a. Single order b. Standard written order c. Standing order d. Stat order 14. A female client with a fecal impaction frequently exhibits which clinical manifestation? a. Increased appetite b. Loss of urge to defecate c. Hard, brown, formed stools d. Liquid or semi-liquid stools 15. Nurse Linda prepares to perform an otoscopic examination on a female client. For proper visualization, the nurse should position the client's ear by: a. Pulling the lobule down and back b. Pulling the helix up and forward c. Pulling the helix up and back d. Pulling the lobule down and forward 16. Which instruction should nurse Tom give to a male client who is having external radiation therapy: a. Protect the irritated skin from sunlight. b. Eat 3 to 4 hours before treatment. c. Wash the skin over regularly. d. Apply lotion or oil to the radiated area when it is red or sore. 17. In assisting a female client for immediate surgery, the nurse In-charge is aware that she should: a. Encourage the client to void following preoperative medication. b. Explore the client’s fears and anxieties about the surgery. c. Assist the client in removing dentures and nail polish. d. Encourage the client to drink water prior to surgery. 18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of excessive food and alcohol. Which assessment finding reflects this diagnosis? a. Blood pressure above normal range. b. Presence of crackles in both lung fields. c. Hyperactive bowel sounds d. Sudden onset of continuous epigastric and back pain. 19. Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns? a. Provide high-fiber, high-fat diet b. Provide high-protein, high-carbohydrate diet. c. Monitor intake to prevent weight gain. d. Provide ice chips or water intake. 20. Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? a. Blood pressure and pulse rate. b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels. 21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The nurse takes which priority action? a. Takes a set of vital signs.
  • 58. b. Call the radiology department for X-ray. c. Reassure the client that everything will be alright. d. Immobilize the leg before moving the client. 22. A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client? a. Place client on reverse isolation. b. Admit the client into a private room. c. Encourage the client to take frequent rest periods. d. Encourage family and friends to visit. 23. A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which priority nursing diagnosis? a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge 24. A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? a. Notify the physician. b. Place the client on the left side in the Trendelenburg position. c. Place the client in high-Fowlers position. d. Stop the total parenteral nutrition. 25. Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse determines that the leadership style used at the trauma center is: a. Autocratic. b. Laissez-faire. c. Democratic. d. Situational 26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution? a. .5 cc b. 5 cc 58 c. 1.5 cc d. 2.5 cc 27. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is: a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour 28. The nurse is aware that the most important nursing action when a client returns from surgery is: a. Assess the IV for type of fluid and rate of flow. b. Assess the client for presence of pain. c. Assess the Foley catheter for patency and urine output d. Assess the dressing for drainage. 29. Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction? a. BP – 80/60, Pulse – 110 irregular b. BP – 90/50, Pulse – 50 regular c. BP – 130/80, Pulse – 100 regular d. BP – 180/100, Pulse – 90 irregular 30. Which is the most appropriate nursing action in obtaining a blood pressure measurement? a. Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart. b. Measure the client’s arm, if you are not sure of the size of cuff to use. c. Have the client recline or sit comfortably in a chair with the forearm at the level of the heart. d. Document the measurement, which extremity was used, and the position that the client was in during the measurement. 31. Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process? a. Assessment b. Evaluation c. Implementation
  • 59. 59 d. Planning and goals 32. Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs? a. Diagnostic test results b. Biographical date c. History of present illness d. Physical examination 33. In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: a. Trochanter roll extending from the crest of the ileum to the mid-thigh. b. Pillows under the lower legs. c. Footboard d. Hip-abductor pillow 34. Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a. Stage I b. Stage II c. Stage III d. Stage IV 35. When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed a. Second intention healing b. Primary intention healing c. Third intention healing d. First intention healing 36. An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find: a. Hypothermia b. Hypertension c. Distended neck veins d. Tachycardia 37. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client receive? a. 0.75 b. 0.6 c. 0.5 d. 0.25 38. A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? a. It’s a common measurement in the metric system. b. It’s the basis for solids in the avoirdupois system. c. It’s the smallest measurement in the apothecary system. d. It’s a measure of effect, not a standard measure of weight or quantity. 39. Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature? a. 40.1 °C b. 38.9 °C c. 48 °C d. 38 °C 40. The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is: a. Accepting limitations while developing assets. b. Increasing loss of muscle tone. c. Failing eyesight, especially close vision. d. Having more frequent aches and pains. 41. The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse incharge can prevent chest tube air leaks by: a. Checking and taping all connections. b. Checking patency of the chest tube. c. Keeping the head of the bed slightly elevated. d. Keeping the chest drainage system below the level of the chest. 42. Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to: a. Check the client’s identification band. b. Ask the client to state his name.
  • 60. c. State the client’s name out loud and wait a client to repeat it. d. Check the room number and the client’s name on the bed. 43. The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of: a. 30 drops/minute b. 32 drops/minute c. 20 drops/minute d. 18 drops/minute 44. If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately? a. Clamp the catheter b. Call another nurse c. Call the physician d. Apply a dry sterile dressing to the site. 45. A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order: a. Palpation, auscultation, and percussion. b. Percussion, palpation, and auscultation. c. Palpation, percussion, and auscultation. d. Auscultation, percussion, and palpation. 46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the: a. Fingertips b. Finger pads c. Dorsal surface of the hand d. Ulnar surface of the hand 47. Which type of evaluation occurs continuously throughout the teaching and learning process? a. Summative b. Informative c. Formative d. Retrospective 48. A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often? a. Twice per year b. Once per year 60 c. Every 2 years d. Once, to establish baseline 49. A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 50. Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral? a. To help the client find appropriate treatment options. b. To provide support for the client and family in coping with terminal illness. c. To ensure that the client gets counseling regarding health care costs. d. To teach the client and family about cancer and its treatment. 51. When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? a. Massaging the area with an astringent every 2 hours. b. Applying an antibiotic cream to the area three times per day. c. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. d. Using a povidone-iodine wash on the ulceration three times per day. 52. Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He should apply the bandage beginning at the client’s: a. Knee b. Ankle c. Lower thigh d. Foot 53. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia
  • 61. 61 d. Hypercalcemia 54. Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience: a. Throbbing headache or dizziness b. Nervousness or paresthesia. c. Drowsiness or blurred vision. d. Tinnitus or diplopia. 55. Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s bedside, the nurse would take which action first? a. Prepare for cardioversion b. Prepare to defibrillate the client c. Call a code d. Check the client’s level of consciousness 56. Nurse Hazel is preparing to ambulate a female client. The best and the safest position for the nurse in assisting the client is to stand: a. On the unaffected side of the client. b. On the affected side of the client. c. In front of the client. d. Behind the client. 57. Nurse Janah is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse determines that the standard of care had been maintained if which of the following data is observed? a. Urine output: 45 ml/hr b. Capillary refill: 5 seconds c. Serum pH: 7.32 d. Blood pressure: 90/48 mmHg 58. Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen? a. Wiping the port with an alcohol swab before inserting the syringe. b. Aspirating a sample from the port on the drainage bag. c. Clamping the tubing of the drainage bag. d. Obtaining the specimen from the urinary drainage bag. 59. Nurse Meredith is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The appropriate nursing action is to: a. Immediately walk out of the client’s room and answer the phone call. b. Cover the client, place the call light within reach, and answer the phone call. c. Finish the bed bath before answering the phone call. d. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call. 60. Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen? a. Ask the client to expectorate a small amount of sputum into the emesis basin. b. Ask the client to obtain the specimen after breakfast. c. Use a sterile plastic container for obtaining the specimen. d. Provide tissues for expectoration and obtaining the specimen. 61. Nurse Ron is observing a male client using a walker. The nurse determines that the client is using the walker correctly if the client: a. Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. b. Puts weight on the hand pieces, moves the walker forward, and then walks into it. c. Puts weight on the hand pieces, slides the walker forward, and then walks into it. d. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor. 62. Nurse Amy has documented an entry regarding client care in the client’s medical record. When checking the entry, the nurse realizes that
  • 62. incorrect information was documented. How does the nurse correct this error? a. Erases the error and writes in the correct information. b. Uses correction fluid to cover up the incorrect information and writes in the correct information. c. Draws one line to cross out the incorrect information and then initials the change. d. Covers up the incorrect information completely using a black pen and writes in the correct information 63. Nurse Ron is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse should: a. Moves the client rapidly from the table to the stretcher. b. Uncovers the client completely before transferring to the stretcher. c. Secures the client safety belts after transferring to the stretcher. d. Instructs the client to move self from the table to the stretcher. 64. Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to use which of the following protective items when giving bed bath? a. Gown and goggles b. Gown and gloves c. Gloves and shoe protectors d. Gloves and goggles 65. Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? a. Crutches b. Single straight-legged cane c. Quad cane d. Walker 66. A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure? 62 a. Prone with head turned toward the side supported by a pillow. b. Sims’ position with the head of the bed flat. c. Right side-lying with the head of the bed elevated 45 degrees. d. Left side-lying with the head of the bed elevated 45 degrees. 67. Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? a. Validity b. Specificity c. Sensitivity d. Reliability 68. Harry knows that he has to protect the rights of human research subjects. Which of the following actions of Harry ensures anonymity? a. Keep the identities of the subject secret b. Obtain informed consent c. Provide equal treatment to all the subjects of the study. d. Release findings only to the participants of the study 69. Patient’s refusal to divulge information is a limitation because it is beyond the control of Tifanny”. What type of research is appropriate for this study? a. Descriptive- correlational b. Experiment c. Quasi-experiment d. Historical 70. Nurse Ronald is aware that the best tool for data gathering is? a. Interview schedule b. Questionnaire c. Use of laboratory data d. Observation 71. Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this? a. Field study b. Quasi-experiment c. Solomon-Four group design
  • 63. 63 d. Post-test only design 72. Cherry notes down ideas that were derived from the description of an investigation written by the person who conducted it. Which type of reference source refers to this? a. Footnote b. Bibliography c. Primary source d. Endnotes 73. When Nurse Trish is providing care to his patient, she must remember that her duty is bound not to do doing any action that will cause the patient harm. This is the meaning of the bioethical principle: a. Non-maleficence b. Beneficence c. Justice d. Solidarity 74. When a nurse in-charge causes an injury to a female patient and the injury caused becomes the proof of the negligent act, the presence of the injury is said to exemplify the principle of: a. Force majeure b. Respondeat superior c. Res ipsa loquitor d. Holdover doctrine 75. Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is: a. The Board can issue rules and regulations that will govern the practice of nursing b. The Board can investigate violations of the nursing law and code of ethics c. The Board can visit a school applying for a permit in collaboration with CHED d. The Board prepares the board examinations 76. When the license of nurse Krina is revoked, it means that she: a. Is no longer allowed to practice the profession for the rest of her life b. Will never have her/his license re-issued since it has been revoked c. May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 d. Will remain unable to practice professional nursing 77. Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process? a. Formulating the research hypothesis b. Review related literature c. Formulating and delimiting the research problem d. Design the theoretical and conceptual framework 78. The leader of the study knows that certain patients who are in a specialized research setting tend to respond psychologically to the conditions of the study. This referred to as : a. Cause and effect b. Hawthorne effect c. Halo effect d. Horns effect 79. Mary finally decides to use judgment sampling on her research. Which of the following actions of is correct? a. Plans to include whoever is there during his study. b. Determines the different nationality of patients frequently admitted and decides to get representations samples from each. c. Assigns numbers for each of the patients, place these in a fishbowl and draw 10 from it. d. Decides to get 20 samples from the admitted patients 80. The nursing theorist who developed transcultural nursing theory is: a. Florence Nightingale b. Madeleine Leininger c. Albert Moore d. Sr. Callista Roy 81. Marion is aware that the sampling method that gives equal chance to all units in the population to get picked is: a. Random b. Accidental c. Quota d. Judgment
  • 64. 82. John plans to use a Likert Scale to his study to determine the: a. Degree of agreement and disagreement b. Compliance to expected standards c. Level of satisfaction d. Degree of acceptance 83. Which of the following theory addresses the four modes of adaptation? a. Madeleine Leininger b. Sr. Callista Roy c. Florence Nightingale d. Jean Watson 84. Ms. Garcia is responsible to the number of personnel reporting to her. This principle refers to: a. Span of control b. Unity of command c. Downward communication d. Leader 85. Ensuring that there is an informed consent on the part of the patient before a surgery is done, illustrates the bioethical principle of: a. Beneficence b. Autonomy c. Veracity d. Non-maleficence 86. Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction? a. Avoid wearing cotton socks. b. Avoid using a nail clipper to cut toenails. c. Avoid wearing canvas shoes. d. Avoid using cornstarch on feet. 87. A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a. Fresh orange slices b. Steamed broccoli c. Ice cream d. Ground beef patties 88. The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure? a. Lithotomy b. Supine c. Prone d. Sims’ left lateral 64 89. Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first? a. Arrange for typing and cross matching of the client’s blood. b. Compare the client’s identification wristband with the tag on the unit of blood. c. Start an I.V. infusion of normal saline solution. d. Measure the client’s vital signs. 90. A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required? a. Independent b. Dependent c. Interdependent d. Intradependent 91. A female client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? a. Assessment b. Diagnosis c. Implementation d. Evaluation 92. Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention? a. To increase blood flow to the heart b. To observe the lower extremities c. To allow the leg muscles to stretch and relax d. To permit veins in the legs to fill with blood. 93. Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? a. Instructing the client to report any itching, swelling, or dyspnea. b. Informing the client that the transfusion usually take 1 ½ to 2 hours. c. Documenting blood administration in the client care record.
  • 65. 65 d. Assessing the client’s vital signs when the transfusion ends. 94. A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a. Give the feedings at room temperature. b. Decrease the rate of feedings and the concentration of the formula. c. Place the client in semi-Fowler's position while feeding. d. Change the feeding container every 12 hours. 95. Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should: a. Do nothing. b. Invert the vial and let it stand for 3 to 5 minutes. c. Shake the vial vigorously. d. Roll the vial gently between the palms. 96. Which intervention should the nurse Trish use when administering oxygen by face mask to a female client? a. Secure the elastic band tightly around the client's head. b. Assist the client to the semi-Fowler position if possible. c. Apply the face mask from the client's chin up over the nose. d. Loosen the connectors between the oxygen equipment and humidifier. 97. The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. 6 hours b. 4 hours c. 3 hours d. 2 hours 98. Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level? a. 1 hour before administering the next dose. b. Immediately before administering the next dose. c. Immediately after administering the next dose. d. 30 minutes after administering the next dose. 99. Nurse May is aware that the main advantage of using a floor stock system is: a. The nurse can implement medication orders quickly. b. The nurse receives input from the pharmacist. c. The system minimizes transcription errors. d. The system reinforces accurate calculations. 100. Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as abnormal? a. Dullness over the liver. b. Bowel sounds occurring every 10 seconds. c. Shifting dullness over the abdomen. d. Vascular sounds heard over the renal arteries.
  • 66. Answers and Rationale – Foundation of Professional Nursing Practice 1. 2. 3. 4. 5. 6. 7. 66 Answer: (D) The actions of a reasonably prudent nurse with similar education and experience. Rationale: The standard of care is determined by the average degree of skill, care, and diligence by nurses in similar circumstances. Answer: (B) I.M Rationale: With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. Answer: (C) “Digoxin 0.125 mg P.O. once daily” Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage. Answer: (A) Ineffective peripheral tissue perfusion related to venous congestion. Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the extremities. Checking the client’s circulation every 15-30 minutes will allow the nurse to adjust the restraints before injury from decreased blood flow occurs. Answer: (A) Prevent stress ulcer 8. 9. 10. 11. 12. 13. 14. Rationale: Curling’s ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers. Answer: (D) Continue to monitor and record hourly urine output Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. Answer: (B) “My ankle feels warm”. Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia. Answer:(A) Have condescending trust and confidence in their subordinates Rationale: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers. Answer: (A) Provides continuous, coordinated and comprehensive nursing services. Rationale: Functional nursing is focused on tasks and activities and not on the care of the patients. Answer: (B) Standard written order Rationale: This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. Answer: (D) Liquid or semi-liquid stools Rationale: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These
  • 67. 67 15. 16. 17. 18. 19. 20. 21. 22. clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite. Answer: (C) Pulling the helix up and back Rationale: To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. Answer: (A) Protect the irritated skin from sunlight. Rationale: Irradiated skin is very sensitive and must be protected with clothing or sunblock. The priority approach is the avoidance of strong sunlight. Answer: (C) Assist the client in removing dentures and nail polish. Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be removed so that cyanosis can be easily monitored by observing the nail beds. Answer: (D) Sudden onset of continuous epigastric and back pain. Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the inflammatory process in the pancreas. Answer: (B) Provide high-protein, highcarbohydrate diet. Rationale: A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day. Answer: (A) Blood pressure and pulse rate. Rationale: The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion. Answer: (D) Immobilize the leg before moving the client. Rationale: If the nurse suspects a fracture, splinting the area before moving the client is imperative. The nurse should call for emergency help if the client is not hospitalized and call for a physician for the hospitalized client. Answer: (B) Admit the client into a private room. 23. 24. 25. 26. 27. 28. 29. 30. 31. Rationale: The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation. Answer: (C) Risk for infection Rationale: Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Deficient knowledge related to the nature of the disorder may be appropriate diagnosis but is not the priority. Answer: (B) Place the client on the left side in the Trendelenburg position. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration. Answer: (A) Autocratic. Rationale: The autocratic style of leadership is a task-oriented and directive. Answer: (D) 2.5 cc Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr. Answer: (B) Assess the client for presence of pain. Rationale: Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client’s comfort. Answer: (A) BP – 80/60, Pulse – 110 irregular Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia. Answer: (A) Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart. Rationale: It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options Answer: (B) Evaluation
  • 68. 32. 33. 34. 35. 36. 37. 38. 39. 40. 68 Rationale: Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes. Answer: (C) History of present illness Rationale: The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-thigh. Rationale: A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Answer: (C) Stage III Rationale: Clinically, a deep crater or without undermining of adjacent tissue is noted. Answer: (A) Second intention healing Rationale: When wounds dehisce, they will allowed to heal by secondary Intention Answer: (D) Tachycardia Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Answer: (A) 0.75 Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.75 ml (or ¾ ml) = X Answer: (D) it’s a measure of effect, not a standard measure of weight or quantity. Rationale: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. Answer: (B) 38.9 °C Rationale: To convert Fahrenheit degreed to Centigrade, use this formula °C = (°F – 32) ÷ 1.8 °C = (102 – 32) ÷ 1.8 °C = 70 ÷ 1.8 °C = 38.9 Answer: (C) Failing eyesight, especially close vision. 41. 42. 43. 44. 45. Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older). Answer: (A) Checking and taping all connections Rationale: Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks. Answer: (A) Check the client’s identification band. Rationale: Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. (If it is removed, it must be replaced). Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert, oriented, and able to understand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable Answer: (B) 32 drops/minute Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute, or 32 drops/minute Answer: (A) Clamp the catheter Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion. Answer: (D) Auscultation, percussion, and palpation. Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed
  • 69. 69 46. 47. 48. 49. 50. 51. before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation. Answer: (D) Ulnar surface of the hand Rationale: The nurse uses the ulnar surface, or ball, of the hand to assess tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary. Answer: (A) Respiratory acidosis Rationale: The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal. Answer: (B) To provide support for the client and family in coping with terminal illness. Rationale: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice. Answer: (C) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. Rationale: Washing the area with normal saline solution and applying a protective dressing are within the nurse’s realm of 52. 53. 54. 55. 56. 57. 58. interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician’s order. Massaging with an astringent can further damage the skin. Answer: (D) Foot Rationale: An elastic bandage should be applied form the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client’s foot. Beginning at the ankle, lower thigh, or knee does not promote venous return. Answer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. Answer: (A) Throbbing headache or dizziness Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops tolerance Answer: (D) Check the client’s level of consciousness Rationale: Determining unresponsiveness is the first step assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output. Answer: (B) On the affected side of the client. Rationale: When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet. Answer: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained to all vital organs in order for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
  • 70. 59. 60. 61. 62. 63. 70 Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system. Answer: (B) Cover the client, place the call light within reach, and answer the phone call. Rationale: Because telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. However, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door should be closed or the room curtains pulled around the bathing area. Answer: (C) Use a sterile plastic container for obtaining the specimen. Rationale: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it. Rationale: When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it. Answer: (C) Draws one line to cross out the incorrect information and then initials the change. Rationale: To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. An error is never erased and correction fluid is never used in the medical record. Answer: (C) Secures the client safety belts after transferring to the stretcher. Rationale: During the transfer of the client after the surgical procedure is complete, the nurse should avoid exposure of the client 64. 65. 66. 67. 68. 69. because of the risk for potential heat loss. Hurried movements and rapid changes in the position should be avoided because these predispose the client to hypotension. At the time of the transfer from the surgery table to the stretcher, the client is still affected by the effects of the anesthesia; therefore, the client should not move self. Safety belts can prevent the client from falling off the stretcher. Answer: (B) Gown and gloves Rationale: Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees. Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. Answer: (D) Reliability Rationale: Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration. Answer: (A) Keep the identities of the subject secret Rationale: Keeping the identities of the research subject secret will ensure anonymity because this will hinder providing link between the information given to whoever is its source. Answer: (A) Descriptive- correlational Rationale: Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection.
  • 71. 71 70. 71. 72. 73. 74. 75. 76. 77. 78. Answer: (C) Use of laboratory data Rationale: Incidence of nosocomial infection is best collected through the use of biophysiologic measures, particularly in vitro measurements, hence laboratory data is essential. Answer: (B) Quasi-experiment Rationale: Quasi-experiment is done when randomization and control of the variables are not possible. Answer: (C) Primary source Rationale: This refers to a primary source which is a direct account of the investigation done by the investigator. In contrast to this is a secondary source, which is written by someone other than the original researcher. Answer: (A) Non-maleficence Rationale: Non-maleficence means do not cause harm or do any action that will cause any harm to the patient/client. To do good is referred as beneficence. Answer: (C) Res ipsa loquitor Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act. Answer: (B) The Board can investigate violations of the nursing law and code of ethics Rationale: Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed. Answer: (C) May apply for re-issuance of his/her license based on certain conditions stipulated in RA 9173 Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license maybe reissued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked. Answer: (B) Review related literature Rationale: After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is based on the study of Elton Mayo and company about the effect of an intervention done to improve the 79. 80. 81. 82. 83. 84. 85. 86. working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation. Answer: (B) Determines the different nationality of patients frequently admitted and decides to get representations samples from each. Rationale: Judgment sampling involves including samples according to the knowledge of the investigator about the participants in the study. Answer: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory on transcultural theory based on her observations on the behavior of selected people within a culture. Answer: (A) Random Rationale: Random sampling gives equal chance for all the elements in the population to be picked as part of the sample. Answer: (A) Degree of agreement and disagreement Rationale: Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study Answer: (B) Sr. Callista Roy Rationale: Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode. Answer: (A) Span of control Rationale: Span of control refers to the number of workers who report directly to a manager. Answer: (B) Autonomy Rationale: Informed consent means that the patient fully understands about the surgery, including the risks involved and the alternative solutions. In giving consent it is done with full knowledge and is given freely. The action of allowing the patient to decide whether a surgery is to be done or not exemplifies the bioethical principle of autonomy. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration.
  • 72. 87. 88. 89. 90. 91. 72 The client should be instructed to cut toenails straight across with nail clippers. Answer: (D) Ground beef patties Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair. Answer: (D) Sims’ left lateral Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client. Answer: (A) Arrange for typing and cross matching of the client’s blood. Rationale: The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options, although appropriate when preparing to administer a blood transfusion, come later. Answer: (A) Independent Rationale: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist. Answer: (D) Evaluation Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the 92. 93. 94. 95. 96. nursing process where the nurse puts the plan of care into action. Answer: (B) To observe the lower extremities Rationale: Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood. Answer :(A) Instructing the client to report any itching, swelling, or dyspnea. Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the transfusion. Answer: (B) Decrease the rate of feedings and the concentration of the formula. Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours. Answer: (D) Roll the vial gently between the palms. Rationale: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action. Answer: (B) Assist the client to the semiFowler position if possible. Rationale: By assisting the client to the semiFowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake.
  • 73. 73 The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen. 97. Answer: (B) 4 hours Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy. 98. Answer: (B) Immediately before administering the next dose. Rationale: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose. 99. Answer: (A) The nurse can implement medication orders quickly. Rationale: A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations. 100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.
  • 74. TEST II - Community Health Nursing and Care of the Mother and Child 1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? a. Inevitable b. Incomplete c. Threatened d. Septic 2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion? a. Age 36 years b. History of syphilis c. History of genital herpes d. History of diabetes mellitus 3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? a. Monitoring weight b. Assessing for edema c. Monitoring apical pulse d. Monitoring temperature 4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy requires: a. Decreased caloric intake b. Increased caloric intake c. Decreased Insulin d. Increase Insulin 5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? 74 a. Excessive fetal activity. b. Larger than normal uterus for gestational age. c. Vaginal bleeding d. Elevated levels of human chorionic gonadotropin. 6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure. 7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: a. Presenting part is 2 cm above the plane of the ischial spines. b. Biparietal diameter is at the level of the ischial spines. c. Presenting part in 2 cm below the plane of the ischial spines. d. Biparietal diameter is 2 cm above the ischial spines. 8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: a. Contractions every 1 ½ minutes lasting 70-80 seconds. b. Maternal temperature 101.2 c. Early decelerations in the fetal heart rate. d. Fetal heart rate baseline 140-160 bpm. 9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR 10. A trial for vaginal delivery after an earlier caesarean, would likely to be given to a gravida, who had:
  • 75. 75 a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. First and second caesareans were for cephalopelvic disproportion. c. First caesarean through a classic incision as a result of severe fetal distress. d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. 11. Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is: a. Talk to the mother first and then to the toddler. b. Bring extra help so it can be done quickly. c. Encourage the mother to hold the child. d. Ignore the crying and screaming. 12. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site? a. Avoid touching the suture line, even when cleaning. b. Place the baby in prone position. c. Give the baby a pacifier. d. Place the infant’s arms in soft elbow restraints. 13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. Feed the infant when he cries. b. Allow the infant to rest before feeding. c. Bathe the infant and administer medications before feeding. d. Weigh and bathe the infant before feeding. 14. Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet? a. Skim milk and baby food. b. Whole milk and baby food. c. Iron-rich formula only. d. Iron-rich formula and baby food. 15. Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be: a. 6 months b. 4 months c. 8 months d. 10 months 16. Which of the following is the most prominent feature of public health nursing? a. It involves providing home care to sick people who are not confined in the hospital. b. Services are provided free of charge to people within the catchments area. c. The public health nurse functions as part of a team providing a public health nursing services. d. Public health nursing focuses on preventive, not curative, services. 17. When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating a. Effectiveness b. Efficiency c. Adequacy d. Appropriateness 18. Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply? a. Department of Health b. Provincial Health Office c. Regional Health Office d. Rural Health Unit 19. Tony is aware the Chairman of the Municipal Health Board is: a. Mayor b. Municipal Health Officer c. Public Health Nurse d. Any qualified physician 20. Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need? a. 1 b. 2 c. 3 d. The RHU does not need any more midwife item.
  • 76. 21. According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement? a. The community health nurse continuously develops himself personally and professionally. b. Health education and community organizing are necessary in providing community health services. c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease. d. The goal of community health nursing is to provide nursing services to people in their own places of residence. 22. Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is? a. Poliomyelitis b. Measles c. Rabies d. Neonatal tetanus 23. May knows that the step in community organizing that involves training of potential leaders in the community is: a. Integration b. Community organization c. Community study d. Core group formation 24. Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing? a. To educate the people regarding community health problems b. To mobilize the people to resolve community health problems c. To maximize the community’s resources in dealing with health problems. d. To maximize the community’s resources in dealing with health problems. 25. Tertiary prevention is needed in which stage of the natural history of disease? a. Pre-pathogenesis b. Pathogenesis c. Prodromal d. Terminal 76 26. The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? a. Intrauterine fetal death. b. Placenta accreta. c. Dysfunctional labor. d. Premature rupture of the membranes. 27. A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be: a. 80 to 100 beats/minute b. 100 to 120 beats/minute c. 120 to 160 beats/minute d. 160 to 180 beats/minute 28. The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to: a. Change the diaper more often. b. Apply talc powder with diaper changes. c. Wash the area vigorously with each diaper change. d. Decrease the infant’s fluid intake to decrease saturating diapers. 29. Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (trisomy 21) is: a. Atrial septal defect b. Pulmonic stenosis c. Ventricular septal defect d. Endocardial cushion defect 30. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is: a. Anemia b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate 31. A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by: a. Menorrhagia b. Metrorrhagia c. Dyspareunia d. Amenorrhea
  • 77. 77 32. Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be: a. Oxygen saturation b. Iron binding capacity c. Blood typing d. Serum Calcium 33. Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is: a. Metabolic alkalosis b. Respiratory acidosis c. Mastitis d. Physiologic anemia 34. Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is: a. A crying 5 year old child with a laceration on his scalp. b. A 4 year old child with a barking coughs and flushed appearance. c. A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms. d. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling. 35. Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected? a. Placenta previa b. Abruptio placentae c. Premature labor d. Sexually transmitted disease 36. A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for: a. Just before bedtime b. After the child has been bathe c. Any time during the day d. Early in the morning 37. In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning? a. Irritability and seizures b. Dehydration and diarrhea c. Bradycardia and hypotension d. Petechiae and hematuria 38. To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching? a. “I should check the diaphragm carefully for holes every time I use it” b. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds” c. “The diaphragm must be left in place for atleast 6 hours after intercourse” d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”. 39. Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for: a. Drooling b. Muffled voice c. Restlessness d. Low-grade fever 40. How should Nurse Michelle guide a child who is blind to walk to the playroom? a. Without touching the child, talk continuously as the child walks down the hall. b. Walk one step ahead, with the child’s hand on the nurse’s elbow. c. Walk slightly behind, gently guiding the child forward. d. Walk next to the child, holding the child’s hand. 41. When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an: a. Loud, machinery-like murmur. b. Bluish color to the lips. c. Decreased BP reading in the upper extremities d. Increased BP reading in the upper extremities. 42. The reason nurse May keeps the neonate in a neutral thermal environment is that when a
  • 78. newborn becomes too cool, the neonate requires: a. Less oxygen, and the newborn’s metabolic rate increases. b. More oxygen, and the newborn’s metabolic rate decreases. c. More oxygen, and the newborn’s metabolic rate increases. d. Less oxygen, and the newborn’s metabolic rate decreases. 43. Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has: a. Stable blood pressure b. Patant fontanelles c. Moro’s reflex d. Voided 44. Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is: a. Baby oil b. Baby lotion c. Laundry detergent d. Powder with cornstarch 45. During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula? a. 6 inches b. 12 inches c. 18 inches d. 24 inches 46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct? a. The older one gets, the more susceptible he becomes to the complications of chicken pox. b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles. c. To prevent an outbreak in the community, quarantine may be imposed by health authorities. d. Chicken pox vaccine is best given when there is an impending outbreak in the community. 78 47. Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy? a. Advise them on the signs of German measles. b. Avoid crowded places, such as markets and movie houses. c. Consult at the health center where rubella vaccine may be given. d. Consult a physician who may give them rubella immunoglobulin. 48. Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is: a. Contact tracing b. Community survey c. Mass screening tests d. Interview of suspects 49. A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect? a. Hepatitis A b. Hepatitis B c. Tetanus d. Leptospirosis 50. Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of “rice water” stools. The client is most probably suffering from which condition? a. Giardiasis b. Cholera c. Amebiasis d. Dysentery 51. The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism? a. Hemophilus influenzae b. Morbillivirus
  • 79. 79 c. Steptococcus pneumoniae d. Neisseria meningitidis 52. The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting the: a. Nasal mucosa b. Buccal mucosa c. Skin on the abdomen d. Skin on neck 53. Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds? a. 3 seconds b. 6 seconds c. 9 seconds d. 10 seconds 54. In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital? a. Mastoiditis b. Severe dehydration c. Severe pneumonia d. Severe febrile disease 55. Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. The estimated number of infants in the barangay would be: a. 45 infants b. 50 infants c. 55 infants d. 65 infants 56. The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? a. DPT b. Oral polio vaccine c. Measles vaccine d. MMR 57. It is the most effective way of controlling schistosomiasis in an endemic area? a. Use of molluscicides b. Building of foot bridges c. Proper use of sanitary toilets d. Use of protective footwear, such as rubber boots 58. Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy? a. 3 skin lesions, negative slit skin smear b. 3 skin lesions, positive slit skin smear c. 5 skin lesions, negative slit skin smear d. 5 skin lesions, positive slit skin smear 59. Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy? a. Macular lesions b. Inability to close eyelids c. Thickened painful nerves d. Sinking of the nosebridge 60. Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do? a. Perform a tourniquet test. b. Ask where the family resides. c. Get a specimen for blood smear. d. Ask if the fever is present every day. 61. Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital? a. Inability to drink b. High grade fever c. Signs of severe dehydration d. Cough for more than 30 days 62. Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage Jimmy? a. Refer the child urgently to a hospital for confinement. b. Coordinate with the social worker to enroll the child in a feeding program. c. Make a teaching plan for the mother, focusing on menu planning for her child. d. Assess and treat the child for health problems like infections and intestinal parasitism.
  • 80. 63. Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to: a. Bring the child to the nearest hospital for further assessment. b. Bring the child to the health center for intravenous fluid therapy. c. Bring the child to the health center for assessment by the physician. d. Let the child rest for 10 minutes then continue giving Oresol more slowly. 64. Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category? a. No signs of dehydration b. Some dehydration c. Severe dehydration d. The data is insufficient. 65. Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as: a. Fast b. Slow c. Normal d. Insignificant 66. Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for a. 1 year b. 3 years c. 5 years d. Lifetime 67. Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution? a. 2 hours b. 4 hours c. 8 hours d. At the end of the day 80 68. The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to: a. 5 months b. 6 months c. 1 year d. 2 years 69. Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is: a. 8 weeks b. 12 weeks c. 24 weeks d. 32 weeks 70. When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following? a. Aspiration b. Sudden infant death syndrome (SIDS) c. Suffocation d. Gastroesophageal reflux (GER) 71. Which finding might be seen in baby James a neonate suspected of having an infection? a. Flushed cheeks b. Increased temperature c. Decreased temperature d. Increased activity level 72. Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication? a. Anemia probably due to chronic fetal hyposia b. Hyperthermia due to decreased glycogen stores c. Hyperglycemia due to decreased glycogen stores d. Polycythemia probably due to chronic fetal hypoxia 73. Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which physical finding is expected? a. A sleepy, lethargic baby b. Lanugo covering the body c. Desquamation of the epidermis d. Vernix caseosa covering the body
  • 81. 81 74. After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate? a. Hypoglycemia b. Jitteriness c. Respiratory depression d. Tachycardia 75. Which symptom would indicate the Baby Alexandra was adapting appropriately to extrauterine life without difficulty? a. Nasal flaring b. Light audible grunting c. Respiratory rate 40 to 60 breaths/minute d. Respiratory rate 60 to 80 breaths/minute 76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information? a. Apply peroxide to the cord with each diaper change b. Cover the cord with petroleum jelly after bathing c. Keep the cord dry and open to air d. Wash the cord with soap and water each day during a tub bath. 77. Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in the healthy neonate? a. Simian crease b. Conjunctival hemorrhage c. Cystic hygroma d. Bulging fontanelle 78. Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons? a. To determine fetal well-being. b. To assess for prolapsed cord c. To assess fetal position d. To prepare for an imminent delivery. 79. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? a. The parents’ willingness to touch and hold the new born. b. The parent’s expression of interest about the size of the new born. c. The parents’ indication that they want to see the newborn. d. The parents’ interactions with each other. 80. Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? a. Applying cold to limit edema during the first 12 to 24 hours. b. Instructing the client to use two or more peripads to cushion the area. c. Instructing the client on the use of sitz baths if ordered. d. Instructing the client about the importance of perineal (kegel) exercises. 81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first? a. “Do you have any chronic illnesses?” b. “Do you have any allergies?” c. “What is your expected due date?” d. “Who will be with you during labor?” 82. A neonate begins to gag and turns a dusky color. What should the nurse do first? a. Calm the neonate. b. Notify the physician. c. Provide oxygen via face mask as ordered d. Aspirate the neonate’s nose and mouth with a bulb syringe. 83. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do? a. Observing the pooling of straw-colored fluid. b. Checking vaginal discharge with nitrazine paper. c. Conducting a bedside ultrasound for an amniotic fluid index. d. Observing for flakes of vernix in the vaginal discharge. 84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is
  • 82. successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? a. Cover his eyes while receiving oxygen. b. Keep her body temperature low. c. Monitor partial pressure of oxygen (Pao2) levels. d. Humidify the oxygen. 85. Which of the following is normal newborn calorie intake? a. 110 to 130 calories per kg. b. 30 to 40 calories per lb of body weight. c. At least 2 ml per feeding d. 90 to 100 calories per kg 86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks? a. 16 to 18 weeks b. 18 to 22 weeks c. 30 to 32 weeks d. 38 to 40 weeks 87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization? a. conjoined twins b. diamniotic dichorionic twins c. diamniotic monochorionic twin d. monoamniotic monochorionic twins 88. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? a. Amniocentesis b. Digital or speculum examination c. External fetal monitoring d. Ultrasound 89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal: a. Increased tidal volume b. Increased expiratory volume 82 c. Decreased inspiratory capacity d. Decreased oxygen consumption 90. Emily has gestational diabetes and it is usually managed by which of the following therapy? a. Diet b. Long-acting insulin c. Oral hypoglycemic d. Oral hypoglycemic drug and insulin 91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure 92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures? a. Antihypertensive agents b. Diuretic agents c. I.V. fluids d. Acetaminophen (Tylenol) for pain 93. Which of the following drugs is the antidote for magnesium toxicity? a. Calcium gluconate (Kalcinate) b. Hydralazine (Apresoline) c. Naloxone (Narcan) d. Rho (D) immune globulin (RhoGAM) 94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results? a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours. d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours. 95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints of fever, nausea, vomiting, malaise, unilateral
  • 83. 83 flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely? a. Asymptomatic bacteriuria b. Bacterial vaginosis c. Pyelonephritis d. Urinary tract infection (UTI) 96. Rh isoimmunization in a pregnant client develops during which of the following conditions? a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies. 97. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? a. Lateral position b. Squatting position c. Supine position d. Standing position 98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find: a. Lethargy 2 days after birth. b. Irritability and poor sucking. c. A flattened nose, small eyes, and thin lips. d. Congenital defects such as limb anomalies. 99. The uterus returns to the pelvic cavity in which of the following time frames? a. 7th to 9th day postpartum. b. 2 weeks postpartum. c. End of 6th week postpartum. d. When the lochia changes to alba. 100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: a. b. c. d. Uterine inversion Uterine atony Uterine involution Uterine discomfort
  • 84. Answers and Rationale – Community Health Nursing and Care of the Mother and Child 1. 2. 3. 4. 5. 6. 7. 8. 84 Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. Answer: (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Answer: (B) Increased caloric intake Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy. Answer: (A) Excessive fetal activity. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds. Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of 9. 10. 11. 12. 13. 14. 15. hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. Answer: (A) Talk to the mother first and then to the toddler. Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. Answer: (D) Place the infant’s arms in soft elbow restraints. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. Answer: (B) Allow the infant to rest before feeding. Rationale: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Answer: (C) Iron-rich formula only. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6
  • 85. 85 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects. Answer: (D) Public health nursing focuses on preventive, not curative, services. Rationale: The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. Answer: (B) Efficiency Rationale: Efficiency is determining whether the goals were attained at the least possible cost. Answer: (D) Rural Health Unit Rationale: R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU. Answer: (A) Mayor Rationale: The local executive serves as the chairman of the Municipal Health Board. Answer: (A) 1 Rationale: Each rural health midwife is given a population assignment of about 5,000. Answer: (B) Health education and community organizing are necessary in providing community health services. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. Answer: (B) Measles Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program. Answer: (D) Core group formation Rationale: In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. Answer: (D) To maximize the community’s resources in dealing with health problems. Rationale: Community organizing is a developmental service, with the goal of developing the people’s self-reliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitations appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease). Answer: (A) Intrauterine fetal death. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC. Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system. Answer: (A) Change the diaper more often. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. Answer: (D) Endocardial cushion defect Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or polysplenia. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. Answer: (C) Blood typing Rationale: Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a woman’s cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling. Rationale: The infant with the airway emergency should be treated first, because of the risk of epiglottitis. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. Answer: (D) Early in the morning
  • 86. 37. 38. 39. 40. 41. 42. 43. 86 Rationale: Based on the nurse’s knowledge of microbiology, the specimen should be collected early in the morning. The rationale for this timing is that, because the female worm lays eggs at night around the perineal area, the first bowel movement of the day will yield the best results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test. Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This condition results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities. Answer: (D) “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”. Rationale: The woman must understand that, although the “fertile” period is approximately mid-cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm should be inserted before every intercourse. Answer: (C) Restlessness Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are associated with a change in color, such as pallor or cyanosis. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow. Rationale: This procedure is generally recommended to follow in guiding a person who is blind. Answer: (A) Loud, machinery-like murmur. Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus. Answer: (C) More oxygen, and the newborn’s metabolic rate increases. Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption, therefore, the newborn increase heat production. Answer: (D) Voided Rationale: Before administering potassium I.V. to any client, the nurse must first check that the client’s kidneys are functioning and that the client is voiding. If the client is not voiding, the 44. 45. 46. 47. 48. 49. 50. 51. 52. nurse should withhold the potassium and notify the physician. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical allergen that is the most common causative factor is laundry detergent. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow enough not to overload the stomach too rapidly. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken pox. Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults. Answer: (D) Consult a physician who may give them rubella immunoglobulin. Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases. Answer: (D) Leptospirosis Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumonia and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children. Answer: (B) Buccal mucosa
  • 87. 87 53. 54. 55. 56. 57. 58. 59. 60. 61. Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric tube. When the foregoing measures are not possible or effective, then urgent referral to the hospital is done. Answer: (A) 45 infants Rationale: To estimate the number of infants, multiply total population by 3%. Answer: (A) DPT Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. Answer: (D) 5 skin lesions, positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. Answer: (B) Ask where the family resides. Rationale: Because malaria is endemic, the first question to determine malaria risk is where the client’s family resides. If the area of residence is not a known endemic area, ask if the child had traveled within the past 6 months, where she was brought and whether she stayed overnight in that area. Answer: (A) Inability to drink 62. 63. 64. 65. 66. 67. 68. 69. Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. Answer: (A) Refer the child urgently to a hospital for confinement. Rationale: “Baggy pants” is a sign of severe marasmus. The best management is urgent referral to a hospital. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. Teach the mother to give Oresol more slowly. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable, sunken eyes, the skin goes back slow after a skin pinch. Answer: (C) Normal Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. Answer: (A) 1 year Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning. Answer: (B) 6 months Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s iron requirement, can no longer be provided by mother’s milk alone. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed enough to sometimes maintain extrauterine life. The lungs are the most immature system during the
  • 88. 70. 71. 72. 73. 74. 75. 76. 88 gestation period. Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation) Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with the supine position. Suffocation would be less likely with an infant supine than prone and the position for GER requires the head of the bed to be elevated. Answer: (C) Decreased temperature Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The neonate’s color often changes with an infection process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores. Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. The serum blood sugar isn’t affected by magnesium sulfate. The neonate would be floppy, not jittery. Answer: (C) Respiratory rate 40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of respiratory distress. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. 77. 78. 79. 80. 81. 82. Infants aren’t given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord from drying and encourages infection. Peroxide could be painful and isn’t recommended. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Bulging fontanelles are a sign of intracranial pressure. Simian creases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can affect the airway. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal wellbeing is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery. Answer: (D) The parents’ interactions with each other. Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the newborn, expressing interest about the newborn's size, and indicating a desire to see the newborn are behaviors indicating parental bonding. Answer: (B) Instructing the client to use two or more peripads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration. Answer: (C) “What is your expected due date?” Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
  • 89. 89 83. 84. 85. 86. 87. Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated. Answer: (A) 110 to 130 calories per kg. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’ gestation, then twins don’t’ gain weight as rapidly as singletons of the same gestational age. The placenta can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so there’s some growth retardation in twins if they remain in utero at 38 to 40 weeks. Answer: (A) conjoined twins 88. 89. 90. 91. 92. Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins. Answer: (D) Ultrasound Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldn’t be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring won’t detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation. Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. The expiratory volume and residual volume decrease as the pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isn’t needed for blood glucose control in the client with gestational diabetes. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Hypomagnesemia isn’t a complication of preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension. Magnesium doesn’t help prevent hemorrhage in preeclamptic clients. Answer: (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion
  • 90. 93. 94. 95. 96. 97. 90 oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid overload resulted. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive. Answer: (C) Pyelonephritis Rationale The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rationale: Rh isoimmunization occurs when Rhpositive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rhpositive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. 98. Answer: (B) Irritability and poor sucking. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies. 99. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution. 100. Answer: (B) Uterine atony Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
  • 91. 91 TEST III - Care of Clients with Physiologic and Psychosocial Alterations 1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is: a. Green liquid b. Solid formed c. Loose, bloody d. Semiformed 2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? a. On the client’s right side b. On the client’s left side c. Directly in front of the client d. Where the client like 3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? a. Check respiration, circulation, neurological response. b. Align the spine, check pupils, and check for hemorrhage. c. Check respirations, stabilize spine, and check circulation. d. Assess level of consciousness and circulation. 4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by: a. Increasing contractility and slowing heart rate. b. Increasing AV conduction and heart rate. c. Decreasing contractility and oxygen consumption. d. Decreasing venous return through vasodilation. 5. Nurse Patricia finds a female client who is postmyocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action? a. Call for help and note the time. b. Clear the airway c. Give two sharp thumps to the precordium, and check the pulse. d. Administer two quick blows. 6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should: a. Plan care so the client can receive 8 hours of uninterrupted sleep each night. b. Monitor vital signs every 2 hours. c. Make sure that the client takes food and medications at prescribed intervals. d. Provide milk every 2 to 3 hours. 7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? a. Stop the I.V. infusion of heparin and notify the physician. b. Continue treatment as ordered. c. Expect the warfarin to increase the PTT. d. Increase the dosage, because the level is lower than normal. 8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? a. 24 hours later, when edema has subsided. b. In the operating room. c. After the ileostomy begin to function. d. When the client is able to begin self-care procedures. 9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in: a. On the side, to prevent obstruction of airway by tongue. b. Flat on back. c. On the back, with knees flexed 15 degrees. d. Flat on the stomach, with the head turned to the side. 10. While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? a. Blood pressure is decreased from 160/90 to 110/70. b. Pulse is increased from 87 to 95, with an occasional skipped beat. c. The client is oriented when aroused from sleep, and goes back to sleep immediately.
  • 92. d. The client refuses dinner because of anorexia. 11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? a. Altered mental status and dehydration b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough 12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit? a. Chest and lower back pain b. Chills, fever, night sweats, and hemoptysis c. Fever of more than 104°F (40°C) and nausea d. Headache and photophobia 13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions? a. Acute asthma b. Bronchial pneumonia c. Chronic obstructive pulmonary disease (COPD) d. Emphysema 14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions? a. Asthma attack b. Respiratory arrest c. Seizure d. Wake up on his own 15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? a. Increased elastic recoil of the lungs b. Increased number of functional capillaries in the alveoli c. Decreased residual volume d. Decreased vital capacity 92 16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication? a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter. b. Increase in systemic blood pressure. c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. d. Increase in intracranial pressure (ICP). 17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: a. Report incidents of diarrhea. b. Avoid foods high in vitamin K c. Use a straight razor when shaving. d. Take aspirin to pain relief. 18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by: a. Leaving the hair intact b. Shaving the area c. Clipping the hair in the area d. Removing the hair with a depilatory. 19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication: a. Bone fracture b. Loss of estrogen c. Negative calcium balance d. Dowager’s hump 20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover: a. Cancerous lumps b. Areas of thickness or fullness c. Changes from previous examinations. d. Fibrocystic masses 21. When caring for a female client who is being treated for hyperthyroidism, it is important to: a. Provide extra blankets and clothing to keep the client warm. b. Monitor the client for signs of restlessness, sweating, and excessive
  • 93. 93 weight loss during thyroid replacement therapy. c. Balance the client’s periods of activity and rest. d. Encourage the client to be active to prevent constipation. 22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: a. Avoid focusing on his weight. b. Increase his activity level. c. Follow a regular diet. d. Continue leading a high-stress lifestyle. 23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a: a. Laminectomy b. Thoracotomy c. Hemorrhoidectomy d. Cystectomy. 24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following? a. Avoid lifting objects weighing more than 5 lb (2.25 kg). b. Lie on your abdomen when in bed c. Keep rooms brightly lit. d. Avoiding straining during bowel movement or bending at the waist. 25. George should be taught about testicular examinations during: a. when sexual activity starts b. After age 69 c. After age 40 d. Before age 20. 26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to: a. Call the physician b. Place a saline-soaked sterile dressing on the wound. c. Take a blood pressure and pulse. d. Pull the dehiscence closed. 27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are: a. A progressively deeper breaths followed by shallower breaths with apneic periods. b. Rapid, deep breathing with abrupt pauses between each breath. c. Rapid, deep breathing and irregular breathing without pauses. d. Shallow breathing with an increased respiratory rate. 28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: a. Tracheal b. Fine crackles c. Coarse crackles d. Friction rubs 29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this change is that: a. The attack is over. b. The airways are so swollen that no air cannot get through. c. The swelling has decreased. d. Crackles have replaced wheezes. 30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should: a. Place the client on his back remove dangerous objects, and insert a bite block. b. Place the client on his side, remove dangerous objects, and insert a bite block. c. Place the client o his back, remove dangerous objects, and hold down his arms. d. Place the client on his side, remove dangerous objects, and protect his head. 31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for? a. Infection of the lung.
  • 94. b. Kinked or obstructed chest tube c. Excessive water in the water-seal chamber d. Excessive chest tube drainage 32. Nurse Maureen is talking to a male client; the client begins choking on his lunch. He’s coughing forcefully. The nurse should: a. Stand him up and perform the abdominal thrust maneuver from behind. b. Lay him down, straddle him, and perform the abdominal thrust maneuver. c. Leave him to get assistance d. Stay with him but not intervene at this time. 33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care? a. General health for the last 10 years. b. Current health promotion activities. c. Family history of diseases. d. Marital status. 34. When performing oral care on a comatose client, Nurse Krina should: a. Apply lemon glycerin to the client’s lips at least every 2 hours. b. Brush the teeth with client lying supine. c. Place the client in a side lying position, with the head of the bed lowered. d. Clean the client’s mouth with hydrogen peroxide. 35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Myocardial infarction (MI) c. Pneumonia d. Tuberculosis 36. Nurse Oliver is working in an outpatient clinic. He has been alerted that there is an outbreak of 94 tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB? a. A 16-year-old female high school student b. A 33-year-old day-care worker c. A 43-yesr-old homeless man with a history of alcoholism d. A 54-year-old businessman 37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done? a. To confirm the diagnosis b. To determine if a repeat skin test is needed c. To determine the extent of lesions d. To determine if this is a primary or secondary infection 38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away? a. Beta-adrenergic blockers b. Bronchodilators c. Inhaled steroids d. Oral steroids 39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia. 40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct? a. The patient is under local anesthesia during the procedure b. The aspirated bone marrow is mixed with heparin. c. The aspiration site is the posterior or anterior iliac crest.
  • 95. 95 d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure. 41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be: a. Call the physician b. Document the patient’s status in his charts. c. Prepare oxygen treatment d. Raise the side rails 42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is: a. Crowd red blood cells b. Are not responsible for the anemia. c. Uses nutrients from other cells d. Have an abnormally short life span of cells. 43. Diagnostic assessment of Francis would probably not reveal: a. Predominance of lymhoblasts b. Leukocytosis c. Abnormal blast cells in the bone marrow d. Elevated thrombocyte counts 44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse? a. Explain the risks of not having the surgery b. Notifying the physician immediately c. Notifying the nursing supervisor d. Recording the client’s refusal in the nurses’ notes 45. During the endorsement, which of the following clients should the on-duty nurse assess first? a. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/ minute. b. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order c. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) 46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using? a. Barbiturates b. Opioids c. Cocaine d. Benzodiazepines 47. A 51-year-old female client tells the nurse incharge that she has found a painless lump in her right breast during her monthly selfexamination. Which assessment finding would strongly suggest that this client's lump is cancerous? a. Eversion of the right nipple and mobile mass b. Nonmobile mass with irregular edges c. Mobile mass that is soft and easily delineated d. Nonpalpable right axillary lymph nodes 48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of cancer?" Which treatment should the nurse name? a. Surgery b. Chemotherapy c. Radiation d. Immunotherapy 49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion
  • 96. according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean? a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis c. Can't assess tumor or regional lymph nodes and no evidence of metastasis d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis 50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? a. "Keep the stoma uncovered." b. "Keep the stoma dry." c. "Have a family member perform stoma care initially until you get used to the procedure." d. "Keep the stoma moist." 51. A 37-year-old client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it's breast cancer. Which type of cancer causes the most deaths in women? a. Breast cancer b. Lung cancer c. Brain cancer d. Colon and rectal cancer 52. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note: a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. b. chest pain, dyspnea, cough, weight loss, and fever. c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side. d. hoarseness and dysphagia. 53. Vic asks the nurse what PSA is. The nurse should reply that it stands for: 96 a. prostate-specific antigen, which is used to screen for prostate cancer. b. protein serum antigen, which is used to determine protein levels. c. pneumococcal strep antigen, which is a bacteria that causes pneumonia. d. Papanicolaou-specific antigen, which is used to screen for cervical cancer. 54. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block? a. "Avoid drinking liquids until the gag reflex returns." b. "Avoid eating milk products for 24 hours." c. "Notify a nurse if you experience blood in your urine." d. "Remain supine for the time specified by the physician." 55. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis? a. Stool Hematest b. Carcinoembryonic antigen (CEA) c. Sigmoidoscopy d. Abdominal computed tomography (CT) scan 56. During a breast examination, which finding most strongly suggests that the Luz has breast cancer? a. Slight asymmetry of the breasts. b. A fixed nodular mass with dimpling of the overlying skin c. Bloody discharge from the nipple d. Multiple firm, round, freely movable masses that change with the menstrual cycle 57. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells? a. Liver b. Colon c. Reproductive tract d. White blood cells (WBCs) 58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a
  • 97. 97 spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client? a. The client lies still. b. The client asks questions. c. The client hears thumping sounds. d. The client wears a watch and wedding band. 59. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct? a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. b. To avoid fractures, the client should avoid strenuous exercise. c. The recommended daily allowance of calcium may be found in a wide variety of foods. d. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement. 60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication? a. Joint pain b. Joint deformity c. Joint flexion of less than 50% d. Joint stiffness 61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30? a. Septic arthritis b. Traumatic arthritis c. Intermittent arthritis d. Gouty arthritis 62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given? a. 15 ml/hour b. 30 ml/hour c. 45 ml/hour d. 50 ml/hour 63. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke? a. Elbow contracture secondary to spasticity b. Loss of muscle contraction decreasing venous return c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus 64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity? a. It appears only in men b. It appears on the distal interphalangeal joint c. It appears on the proximal interphalangeal joint d. It appears on the dorsolateral aspect of the interphalangeal joint. 65. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis? a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t 66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices? a. A walker is a better choice than a cane. b. The cane should be used on the affected side c. The cane should be used on the unaffected side d. A client with osteoarthritis should be encouraged to ambulate without the cane 67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
  • 98. a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). b. 21 U regular insulin and 9 U NPH. c. 10 U regular insulin and 20 U NPH. d. 20 U regular insulin and 10 U NPH. 68. Nurse Len should expect to administer which medication to a client with gout? a. aspirin b. furosemide (Lasix) c. colchicines d. calcium gluconate (Kalcinate) 69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which of the following glands? a. Adrenal cortex b. Pancreas c. Adrenal medulla d. Parathyroid 70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client? a. They contain exudate and provide a moist wound environment. b. They protect the wound from mechanical trauma and promote healing. c. They debride the wound and promote healing by secondary intention. d. They prevent the entrance of microorganisms and minimize wound discomfort. 71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find? a. Hyperkalemia b. Reduced blood urea nitrogen (BUN) c. Hypernatremia d. Hyperglycemia 72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake 98 c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered 73. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: a. urine glucose level. b. fasting blood glucose level. c. serum fructosamine level. d. glycosylated hemoglobin level. 74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction? a. 10:00 am b. Noon c. 4:00 pm d. 10:00 pm 75. The adrenal cortex is responsible for producing which substances? a. Glucocorticoids and androgens b. Catecholamines and epinephrine c. Mineralocorticoids and catecholamines d. Norepinephrine and epinephrine 76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery? a. Hypocalcemia b. Hyponatremia c. Hyperkalemia d. Hypermagnesemia 77. Which laboratory test value is elevated in clients who smoke and can't be used as a general indicator of cancer? a. Acid phosphatase level b. Serum calcitonin level c. Alkaline phosphatase level d. Carcinoembryonic antigen level
  • 99. 99 78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia? a. Nights sweats, weight loss, and diarrhea b. Dyspnea, tachycardia, and pallor c. Nausea, vomiting, and anorexia d. Itching, rash, and jaundice 79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says: a. The baby can get the virus from my placenta." b. "I'm planning on starting on birth control pills." c. "Not everyone who has the virus gives birth to a baby who has the virus." d. "I'll need to have a C-section if I become pregnant and have a baby." 80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction? a. "Put on disposable gloves before bathing." b. "Sterilize all plates and utensils in boiling water." c. "Avoid sharing such articles as toothbrushes and razors." d. "Avoid eating foods from serving dishes shared by other family members." 81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a. Pallor, bradycardia, and reduced pulse pressure b. Pallor, tachycardia, and a sore tongue c. Sore tongue, dyspnea, and weight gain d. Angina, double vision, and anorexia 82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first? a. Page an anesthesiologist immediately and prepare to intubate the client. b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs. d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered. 83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include: a. weight gain. b. fine motor tremors. c. respiratory acidosis. d. bilateral hearing loss. 84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell? a. Neutrophil b. Basophil c. Monocyte d. Lymphocyte 85. In an individual with Sjögren's syndrome, nursing care should focus on: a. moisture replacement. b. electrolyte balance. c. nutritional supplementation. d. arrhythmia management. 86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order: a. enzyme-linked immunosuppressant assay (ELISA) test. b. electrolyte panel and hemogram. c. stool for Clostridium difficile test. d. flat plate X-ray of the abdomen. 87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
  • 100. a. E-rosette immunofluorescence. b. quantification of T-lymphocytes. c. enzyme-linked immunosorbent assay (ELISA). d. Western blot test with ELISA. 88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify? a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels b. Low levels of urine constituents normally excreted in the urine c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels d. Electrolyte imbalance that could affect the blood's ability to coagulate properly 89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters? a. Platelet count, prothrombin time, and partial thromboplastin time b. Platelet count, blood glucose levels, and white blood cell (WBC) count c. Thrombin time, calcium levels, and potassium levels d. Fibrinogen level, WBC, and platelet count 90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen? a. Bread b. Carrots c. Orange d. Strawberries 91. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first? a. A client with hepatitis A who states, “My arms and legs are itching.” b. A client with cast on the right leg who states, “I have a funny feeling in my right leg.” c. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.” 100 d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.” 92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first? a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain. c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours. d. A 62-year-old who had an abdominalperineal resection three days ago; client complaints of chills. 93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed? a. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit. b. The client supports his head and neck when turning his head to the right. c. The client spontaneously flexes his wrist when the blood pressure is obtained. d. The client is drowsy and complains of sore throat. 94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions? a. Encourage the client to change positions frequently in bed. b. Administer Demerol 50 mg IM q 4 hours and PRN. c. Apply warmth to the abdomen with a heating pad. d. Use comfort measures and pillows to position the client. 95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first? a. Assess for a bruit and a thrill. b. Warm the dialysate solution. c. Position the client on the left side.
  • 101. 101 d. Insert a Foley catheter 96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective? a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg. b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg. c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg. 97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate? a. Ask the woman’s family to provide personal items such as photos or mementos. b. Select a room with a bed by the door so the woman can look down the hall. c. Suggest the woman eat her meals in the room with her roommate. d. Encourage the woman to ambulate in the halls twice a day. 98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective? a. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker. b. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. c. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker. d. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance. 99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason? a. Increased sensitivity to the side effects of medications. b. Decreased visual, auditory, and gustatory abilities. c. Isolation from their families and familiar surroundings. d. Decrease musculoskeletal function and mobility. 100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next? a. Encourage the client to perform pursed lip breathing. b. Check the client’s temperature. c. Assess the client’s potassium level. d. Increase the client’s oxygen flow rate.
  • 102. Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations 1. 2. 3. 4. 5. 6. 7. 8. 102 Answer: (C) Loose, bloody Rationale: Normal bowel function and softformed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed. Answer: (A) On the client’s right side Rationale: The client has left visual field blindness. The client will see only from the right side. Answer: (C) Check respirations, stabilize spine, and check circulation Rationale: Checking the airway would be priority, and a neck injury should be suspected. Answer: (D) Decreasing venous return through vasodilation. Rationale: The significant effect of nitroglycerin is vasodilation and decreased venous return, so the heart does not have to work hard. Answer: (A) Call for help and note the time. Rationale: Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, of if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedure Answer: (C) Make sure that the client takes food and medications at prescribed intervals. Rationale: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that does accumulate. Answer: (B) Continue treatment as ordered. Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level. Answer: (B) In the operating room. Rationale: The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in 9. 10. 11. 12. 13. 14. 15. digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. Answer: (B) Flat on back. Rationale: To avoid the complication of a painful spinal headache that can last for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively. Headaches are believed to be causes by the seepage of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral spinal fluid pressures are equalized, which avoids trauma to the neurons. Answer: (C) The client is oriented when aroused from sleep, and goes back to sleep immediately. Rationale: This finding suggest that the level of consciousness is decreasing. Answer: (A) Altered mental status and dehydration Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly clients may first appear with only an altered lentil status and dehydration due to a blunted immune response. Answer: (B) Chills, fever, night sweats, and hemoptysis Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn’t usual. Clients with TB typically have lowgrade fevers, not higher than 102°F (38.9°C). Nausea, headache, and photophobia aren’t usual TB symptoms. Answer:(A) Acute asthma Rationale: Based on the client’s history and symptoms, acute asthma is the most likely diagnosis. He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too young to have developed (COPD) and emphysema. Answer: (B) Respiratory arrest Rationale: Narcotics can cause respiratory arrest if given in large quantities. It’s unlikely the client will have asthma attack or a seizure or wake up on his own. Answer: (D) Decreased vital capacity Rationale: Reduction in vital capacity is a normal physiologic change includes decreased
  • 103. 103 16. 17. 18. 19. 20. 21. elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren’t as significant as PVCs in the situation. Answer: (B) Avoid foods high in vitamin K Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but isn’t effect of taking an anticoagulant. An electric razornot a straight razor-should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen should be used to pain relief. Answer: (C) Clipping the hair in the area Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions and depilatories can irritate the skin. Answer: (A) Bone fracture Rationale: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones. Estrogen deficiencies result from menopause-not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis. Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature. Answer: (C) Changes from previous examinations. Rationale: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant. Answer: (C) Balance the client’s periods of activity and rest. Rationale: A client with hyperthyroidism needs to be encouraged to balance periods of 22. 23. 24. 25. 26. 27. activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Answer: (B) Increase his activity level. Rationale: The client should be encouraged to increase his activity level. aintaining an ideal weight; following a low-cholesterol, low sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis. Answer: (A) Laminectomy Rationale: The client who has had spinal surgery, such as laminectomy, must be log rolled to keep the spinal column straight when turning. Thoracotomy and cystectomy may turn themselves or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery. Answer: (D) Avoiding straining during bowel movement or bending at the waist. Rationale: The client should avoid straining, lifting heavy objects, and coughing harshly because these activities increase intraocular pressure. Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either the side or back. The client should avoid bright light by wearing sunglasses. Answer: (D) Before age 20. Rationale: Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self- examination before age 20, preferably when he enters his teens. Answer: (B) Place a saline-soaked sterile dressing on the wound. Rationale: The nurse should first place salinesoaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client’s vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it. Answer: (A) A progressively deeper breaths followed by shallower breaths with apneic periods. Rationale: Cheyne-Strokes respirations are breaths that become progressively deeper fallowed by shallower respirations with
  • 104. 28. 29. 30. 31. 32. 104 apneas periods. Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath, and equal depth between each breath. Kussmaul’s respirationa are rapid, deep breathing without pauses. Tachypnea is shallow breathing with increased respiratory rate. Answer: (B) Fine crackles Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. Answer: (B) The airways are so swollen that no air cannot get through Rationale: During an acute attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can’t get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles do not replace wheezes during an acute asthma attack. Answer: (D) Place the client on his side, remove dangerous objects, and protect his head. Rationale: During the active seizure phase, initiate precautions by placing the client on his side, removing dangerous objects, and protecting his head from injury. A bite block should never be inserted during the active seizure phase. Insertion can break the teeth and lead to aspiration. Answer: (B) Kinked or obstructed chest tube Rationales: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage won’t cause a tension pneumothorax. Excessive water won’t affect the chest tube drainage. Answer: (D) Stay with him but not intervene at this time. Rationale: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, she should lay him down. A nurse should never leave a choking client alone. 33. 34. 35. 36. 37. Answer: (B) Current health promotion activities Rationale: Recognizing an individual’s positive health measures is very useful. General health in the previous 10 years is important, however, the current activities of an 84 year old client are most significant in planning care. Family history of disease for a client in later years is of minor significance. Marital status information may be important for discharge planning but is not as significant for addressing the immediate medical problem. Answer: (C) Place the client in a side lying position, with the head of the bed lowered. Rationale: The client should be positioned in a side-lying position with the head of the bed lowered to prevent aspiration. A small amount of toothpaste should be used and the mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth with the client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used. Answer: (C) Pneumonia Rationale: Fever productive cough and pleuritic chest pain are common signs and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with respiration, unlike the constant chest pain during an MI; so this client most likely isn’t having an MI. the client with TB typically has a cough producing blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s suspicions. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism Rationale: Clients who are economically disadvantaged, malnourished, and have reduced immunity, such as a client with a history of alcoholism, are at extremely high risk for developing TB. A high school student, day- care worker, and businessman probably have a much low risk of contracting TB. Answer: (C ) To determine the extent of lesions Rationale: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There can be false-positive and false-negative
  • 105. 105 38. 39. 40. 41. 42. 43. 44. 45. skin test results. A chest X-ray can’t determine if this is a primary or secondary infection. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta- adrenergic blockers aren’t used to treat asthma and can cause broncho- constriction. Inhaled oral steroids may be given to reduce the inflammation but aren’t used for emergency relief. Answer: (C) Chronic obstructive bronchitis Rationale: Because of this extensive smoking history and symptoms the client most likely has chronic obstructive bronchitis. Client with ARDS have acute symptoms of hypoxia and typically need large amounts of oxygen. Clients with asthma and emphysema tend not to have chronic cough or peripheral edema. Answer: (A) The patient is under local anesthesia during the procedure Rationale: Before the procedure, the patient is administered with drugs that would help to prevent infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is placed under general anesthesia. Answer: (D) Raise the side rails Rationale: A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse should be raising the side rails to ensure patients safety. Answer: (A) Crowd red blood cells Rationale: The excessive production of white blood cells crowd out red blood cells production which causes anemia to occur. Answer: (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased production of leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells within the bone marrow, spleen and liver. Answer: (A) Explain the risks of not having the surgery Rationale: The best initial response is to explain the risks of not having the surgery. If the client understands the risks but still refuses the nurse should notify the physician and the nurse supervisor and then record the client’s refusal in the nurses’ notes. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial 46. 47. 48. 49. fibrillation and is receiving L.V. dilitiazem (Cardizem) Rationale: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then the 58- year-old client admitted 2 days ago with heart failure (his signs and symptoms are resolving and don’t require immediate attention). The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires timeconsuming supportive measures. Answer: (C) Cocaine Rationale: Because of the client’s age and negative medical history, the nurse should question her about cocaine use. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory depression and slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. Answer: (B) Nonmobile mass with irregular edges Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer. Answer: (C) Radiation Rationale: The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer is diagnosed in an early stage, which is rare. Immunotherapy isn't used to treat vaginal cancer. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal
  • 106. 50. 51. 52. 53. 106 regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3. Answer: (D) "Keep the stoma moist." Rationale: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. Answer: (B) Lung cancer Rationale: Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women, followed (in descending order) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs and affects the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand muscles on the affected side suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a client with lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the lung tumor is compressing the esophagus. 53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer. Rationale: PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The other answers are incorrect. 54. 55. 56. 57. 58. 59. Answer: (D) "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria. Answer: (C) Sigmoidoscopy Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer. Answer: (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. Answer: (A) Liver Rationale: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites. Answer: (D) The client wears a watch and wedding band. Rationale: During an MRI, the client should wear no metal objects, such as jewelry, because the strong magnetic field can pull on them, causing injury to the client and (if they fly off) to others. The client must lie still during the MRI but can talk to those performing the test by way of the microphone inside the scanner tunnel. The client should hear thumping sounds, which are caused by the sound waves thumping on the magnetic field. Answer: (C) The recommended daily allowance of calcium may be found in a wide variety of foods.
  • 107. 107 60. 61. 62. 63. Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. It's often, though not always, possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women over 35 who are at risk. Strenuous exercise won't cause fractures. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections. Joint pain may be an indication, not a contraindication, for arthroscopy. Joint deformity and joint stiffness aren't contraindications for this procedure. Answer: (D) Gouty arthritis Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the joints, especially those in the feet and legs. Urate deposits don't occur in septic or traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to inflammation of the synovial lining. Traumatic arthritis results from blunt trauma to a joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint effusions, especially in the knees. Answer: (B) 30 ml/hou Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin per milliliter of solution. The equation is set up as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour. Answer: (B) Loss of muscle contraction decreasing venous return Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction decreases venous return and may cause swelling of the affected extremity. Contractures, or bony calcifications may occur with a stroke, but don’t appear with swelling. DVT may develop in clients with a stroke but is 64. 65. 66. 67. 68. 69. more likely to occur in the lower extremities. A stroke isn’t linked to protein loss. Answer: (B) It appears on the distal interphalangeal joint Rationale: Heberden’s nodes appear on the distal interphalageal joint on both men and women. Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal joint. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is. Clients have dislocations and subluxations in both disorders. Answer: (C) The cane should be used on the unaffected side Rationale: A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker, or other assistive device as needed; their use takes weight and stress off joints. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used to reverse a negative calcium balance and relieve muscle cramps, not to treat gout. Answer: (A) Adrenal cortex Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of
  • 108. 70. 71. 72. 73. 74. 108 potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. Answer: (C) They debride the wound and promote healing by secondary intention Rationale: For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings protect the wound from mechanical trauma and promote healing. Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia. Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load. Answer: (D) glycosylated hemoglobin level. Rationale: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client 75. 76. 77. 78. 79. is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m. Answer: (A) Glucocorticoids and androgens Rationale: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines— epinephrine and norepinephrine. Answer: (A) Hypocalcemia Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery. Answer: (D) Carcinoembryonic antigen level Rationale: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can't be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful. An elevated acid phosphatase level may indicate prostate cancer. An elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum calcitonin level usually signals thyroid cancer. Answer: (B) Dyspnea, tachycardia, and pallor Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction. Answer: (D) "I'll need to have a C-section if I become pregnant and have a baby." Rationale: The human immunodeficiency virus (HIV) is transmitted from mother to child via
  • 109. 109 80. 81. 82. 83. the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who's HIV positive can give birth to a baby who's HIV negative. Answer: (C) "Avoid sharing such articles as toothbrushes and razors." Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn't share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members. HIV isn't transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS. Answer: (B) Pallor, tachycardia, and a sore tongue Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. Rationale: To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator as prescribed. The physician is likely to order additional medications, such as antihistamines and corticosteroids; if these medications don't relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the first priority. Answer: (D) bilateral hearing loss. Rationale: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the 84. 85. 86. 87. therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory alkalosis, not respiratory acidosis. Answer: (D) Lymphocyte Rationale: The lymphocyte provides adaptive immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Adaptive immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production. Answer: (A) moisture replacement. Rationale: Sjogren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome. Answer: (C) stool for Clostridium difficile test. Rationale: Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel and hemogram may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea. Answer: (D) Western blot test with ELISA. Rationale: HIV infection is detected by analyzing blood for antibodies to HIV, which form approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone. E-rosette immunofluorescence is used to detect viruses
  • 110. 88. 89. 90. 91. 92. 93. 94. 110 in general; it doesn't confirm HIV infection. Quantification of T-lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Rationale: Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery. If the HCT and Hb levels decrease during surgery because of blood loss, the potential need for a transfusion increases. Possible renal failure is indicated by elevated BUN or creatinine levels. Urine constituents aren't found in the blood. Coagulation is determined by the presence of appropriate clotting factors, not electrolytes. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time Rationale: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC. Answer: (D) Strawberries Rationale: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions. Answer: (B) A client with cast on the right leg who states, “I have a funny feeling in my right leg.” Rationale: It may indicate neurovascular compromise, requires immediate assessment. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills. Rationale: The client is at risk for peritonitis; should be assessed for further symptoms and infection. Answer: (C) The client spontaneously flexes his wrist when the blood pressure is obtained. Rationale: Carpal spasms indicate hypocalcemia. Answer: (D) Use comfort measures and pillows to position the client. Rationale: Using comfort measures and pillows to position the client is a nonpharmacological methods of pain relief. 95. Answer: (B) Warm the dialysate solution. Rationale: Cold dialysate increases discomfort. The solution should be warmed to body temperature in warmer or heating pad; don’t use microwave oven. 96. Answer: (C) The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg. Rationale: The cane acts as a support and aids in weight bearing for the weaker right leg. 97. Answer: (A) Ask the woman’s family to provide personal items such as photos or mementos. Rationale: Photos and mementos provide visual stimulation to reduce sensory deprivation. 98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward. Rationale: A walker needs to be picked up, placed down on all legs. 99. Answer: (C) Isolation from their families and familiar surroundings. Rationale: Gradual loss of sight, hearing, and taste interferes with normal functioning. 100. Answer: (A) Encourage the client to perform pursed lip breathing. Rationale: Purse lip breathing prevents the collapse of lung unit and helps client control rate and depth of breathing.
  • 111. 111 TEST IV - Care of Clients with Physiologic and Psychosocial Alterations 1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection? a. Sudden weight loss b. Polyuria c. Hypertension d. Shock 2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease: a. Pain b. Weight c. Hematuria d. Hypertension 3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to: a. Decrease the total basal metabolic rate. b. Maintain the function of the parathyroid glands. c. Block the formation of thyroxine by the thyroid gland. d. Decrease the size and vascularity of the thyroid gland. 4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with: a. Liver disease b. Hypertension c. Type 2 diabetes d. Hyperthyroidism 5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: a. Ascites b. Nystagmus c. Leukopenia d. Polycythemia 6. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to: a. Eliminate foods high in cellulose. b. Decrease fluid intake at meal times. c. Avoid foods that in the past caused flatus. d. Adhere to a bland diet prior to social events. 7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should: a. Lie on my left side while instilling the irrigating solution.” b. Keep the irrigating container less than 18 inches above the stoma.” c. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowel.” d. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.” 8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to: a. Administer Kayexalate b. Restrict foods high in protein c. Increase oral intake of cheese and milk. d. Administer large amounts of normal saline via I.V. 9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide: a. 18 gtt/min b. 28 gtt/min c. 32 gtt/min d. 36 gtt/min 10. Terence suffered from burn injury. Using the rule of nines, which has the largest percent of burns? a. Face and neck b. Right upper arm and penis c. Right thigh and penis d. Upper trunk 11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling
  • 112. from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed: a. Reactive pupils b. A depressed fontanel c. Bleeding from ears d. An elevated temperature 12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker? a. take the pulse rate once a day, in the morning upon awakening b. May be allowed to use electrical appliances c. Have regular follow up care d. May engage in contact sports 13. The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. c. Oxygen is administered best using a nonrebreathing mask d. Blood gases are monitored using a pulse oximeter. 14. Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this position: a. Reduce incisional pain. b. Facilitate ventilation of the left lung. c. Equalize pressure in the pleural space. d. Increase venous return 15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse's highest priority of information would be: a. Food and fluids will be withheld for at least 2 hours. b. Warm saline gargles will be done q 2h. c. Coughing and deep-breathing exercises will be done q2h. 112 d. Only ice chips and cold liquids will be allowed initially. 16. Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: a. hypernatremia. b. hypokalemia. c. hyperkalemia. d. hypercalcemia. 17. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. d. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex. 18. Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating her kidneys, the nurse should keep which anatomical fact in mind? a. The left kidney usually is slightly higher than the right one. b. The kidneys are situated just above the adrenal glands. c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8") wide. d. The kidneys lie between the 10th and 12th thoracic vertebrae. 19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is: a. Increased pH with decreased hydrogen ions.
  • 113. 113 b. Increased serum levels of potassium, magnesium, and calcium. c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl. d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%. 20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide? a. Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin. b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ. c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found. d. Alteration in the size, shape, and organization of differentiated cells. 21. During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer? a. Squamous cell carcinoma b. Multiple myeloma c. Leukemia d. Kaposi's sarcoma 22. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia? a. To prevent confusion b. To prevent seizures c. To prevent cerebrospinal fluid (CSF) leakage d. To prevent cardiac arrhythmias 23. A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a. Auscultate bowel sounds. b. Palpate the abdomen. c. Change the client's position. d. Insert a rectal tube. 24. Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially? a. Lying on the right side with legs straight b. Lying on the left side with knees bent c. Prone with the torso elevated d. Bent over with hands touching the floor 25. A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the nurse interpret this finding? a. Blood supply to the stoma has been interrupted. b. This is a normal finding 1 day after surgery. c. The ostomy bag should be adjusted. d. An intestinal obstruction has occurred. 26. Anthony suffers burns on the legs, which nursing intervention helps prevent contractures? a. Applying knee splints b. Elevating the foot of the bed c. Hyperextending the client's palms d. Performing shoulder range-of-motion exercises 27. Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. b. Urine output of 20 ml/hour. c. White pulmonary secretions. d. Rectal temperature of 100.6° F (38° C). 28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should: a. Turn him frequently. b. Perform passive range-of-motion (ROM) exercises. c. Reduce the client's fluid intake. d. Encourage the client to use a footboard.
  • 114. 29. Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent? a. With a circular motion, to enhance absorption. b. With an upward motion, to increase blood supply to the affected area c. In long, even, outward, and downward strokes in the direction of hair growth d. In long, even, outward, and upward strokes in the direction opposite hair growth 30. Nurse Kate is aware that one of the following classes of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation is: a. Beta -adrenergic blockers b. Calcium channel blocker c. Narcotics d. Nitrates 31. A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention? a. High Fowler’s b. Raised 10 degrees c. Raised 30 degrees d. Supine position 32. The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility? a. Beta-adrenergic blockers b. Calcium channel blocker c. Diuretics d. Inotropic agents 33. A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated lowdensity lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client? a. Fiber intake of 25 to 30 g daily b. Less than 30% of calories from fat c. Cholesterol intake of less than 300 mg daily d. Less than 10% of calories from saturated fat 114 34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality? a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit b. The CCU nurse notifies the on-call physician about a change in the client’s condition c. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress. d. At the client’s request, the CCU nurse updates the client’s wife on his condition 35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take first? a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes. b. Check endotracheal tube placement. c. Obtain an arterial blood gas (ABG) sample. d. Administer atropine, 1 mg L.V. 36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following? a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg 37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate? a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
  • 115. 115 c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel 38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted? a. Pancytopenia b. Idiopathic thrombocytopemic purpura (ITP) c. Disseminated intravascular coagulation (DIC) d. Heparin-associated thrombosis and thrombocytopenia (HATT) 39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)? a. Acetylsalicylic acid (ASA) b. Corticosteroids c. Methotrezate d. Vitamin K 40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this? a. Allogeneic b. Autologous c. Syngeneic d. Xenogeneic 41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway? a. Release of Calcium b. Release of tissue thromboplastin c. Conversion of factors XII to factor XIIa d. Conversion of factor VIII to factor VIIIa 42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias? a. Dressler’s syndrome b. Polycythemia c. Essential thrombocytopenia d. Von Willebrand’s disease 43. The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’s disease? a. Pericarditis b. Night sweat c. Splenomegaly d. Persistent hypothermia 44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed? a. Blood pressure b. Bowel sounds c. Heart sounds d. Breath sounds 45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system? a. Brain b. Muscle spasm c. Renal dysfunction d. Myocardial irritability 46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)? a. Less than 5 years b. 5 to 7 years c. 10 years d. More than 10 years 47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC? a. Low platelet count b. Elevated fibrinogen levels c. Low levels of fibrin degradation products d. Reduced prothrombin time 48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis? a. Influenza b. Sickle cell anemia c. Leukemia d. Hodgkin’s disease
  • 116. 49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? a. AB Rh-positive b. A Rh-positive c. A Rh-negative d. O Rh-positive Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. 50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician? a. “I should contact the physician if Stacy has difficulty in sleeping”. b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. c. “My physician should be called if Stacy is irritable and unhappy”. d. “Should Stacy have continued hair loss, I need to call the doctor”. 51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is: a. “Stacy looks very nice wearing a hat”. b. “You should not worry about her hair, just be glad that she is alive”. c. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”. d. “This is only temporary; Stacy will regrow new hair in 3-6 months, but may be different in texture”. 52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should: a. Provide frequent mouthwash with normal saline. b. Apply viscous Lidocaine to oral ulcers as needed. c. Use lemon glycerine swabs every 2 hours. d. Rinse mouth with Hydrogen Peroxide. 53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is 116 red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is: a. Notify the physician b. Flush the IV line with saline solution c. Immediately discontinue the infusion d. Apply an ice pack to the site, followed by warm compress. 54. The term “blue bloater” refers to a male client which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema 55. The term “pink puffer” refers to the female client with which of the following conditions? a. Adult respiratory distress syndrome (ARDS) b. Asthma c. Chronic obstructive bronchitis d. Emphysema 56. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values? a. 15 mm Hg b. 30 mm Hg c. 40 mm Hg d. 80 mm Hg 57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis 58. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions? a. Asthma attack b. Pulmonary embolism c. Respiratory failure d. Rheumatoid arthritis
  • 117. 117 Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver: 59. Which laboratory test indicates liver cirrhosis? a. Decreased red blood cell count b. Decreased serum acid phosphate level c. Elevated white blood cell count d. Elevated serum aminotransferase 60. 60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of: a. Impaired clotting mechanism b. Varix formation c. Inadequate nutrition d. Trauma of invasive procedure 61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition? a. Increased urine output b. Altered level of consciousness c. Decreased tendon reflex d. Hypotension 62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be: a. “I’ll see if your physician is in the hospital”. b. “Maybe you’re reacting to the drug; I will withhold the next dose”. c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”. d. “Frequently, bowel movements are needed to reduce sodium level”. 63. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm? a. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count, increased white blood (WBC) count. b. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. c. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count. d. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. 64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first? a. Call for help. b. Obtain vital signs c. Ask the client to “lift up” d. Apply gloves and assess the groin site 65. Which of the following treatment is a suitable surgical intervention for a client with unstable angina? a. Cardiac catheterization b. Echocardiogram c. Nitroglycerin d. Percutaneous transluminal coronary angioplasty (PTCA) 66. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is: a. Anaphylactic shock b. Cardiogenic shock c. Distributive shock d. Myocardial infarction (MI) 67. A client with hypertension asks the nurse which factors can cause blood pressure to drop to normal levels? a. Kidneys’ excretion to sodium only. b. Kidneys’ retention of sodium and water c. Kidneys’ excretion of sodium and water d. Kidneys’ retention of sodium and excretion of water 68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is: a. It dilates peripheral blood vessels. b. It decreases sympathetic cardioacceleration. c. It inhibits the angiotensin-coverting enzymes d. It inhibits reabsorption of sodium and water in the loop of Henle.
  • 118. 69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is: a. Elavated serum complement level b. Thrombocytosis, elevated sedimentation rate c. Pancytopenia, elevated antinuclear antibody (ANA) titer d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels 70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate? a. “Your son had a mild concussion, acetaminophen is strong enough.” b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.” c. “Narcotics are avoided after a head injury because they may hide a worsening condition.” d. Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).” 71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result? a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) b. Emergent; the client is poorly oxygenated c. Normal d. Significant; the client has alveolar hypoventilation 72. When prioritizing care, which of the following clients should the nurse Olivia assess first? a. A 17-year-old client’s 24-hours postappendectomy b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome c. A 50-year-old client 3 days postmyocardial infarction d. A 50-year-old client with diverticulitis 118 73. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout? a. Replaces estrogen b. Decreases infection c. Decreases inflammation d. Decreases bone demineralization 74. Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct? a. Osteoarthritis is rarely debilitating b. Osteoarthritis is a rare form of arthritis c. Osteoarthritis is the most common form of arthritis d. Osteoarthritis afflicts people over 60 75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications? a. Exophthalmos b. Thyroid storm c. Myxedema coma d. Tibial myxedema 76. Nurse Sugar is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? a. Pitting edema of the legs b. An irregular apical pulse c. Dry mucous membranes d. Frequent urination 77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus? a. Above-normal urine and serum osmolality levels b. Below-normal urine and serum osmolality levels c. Above-normal urine osmolality level, below-normal serum osmolality level d. Below-normal urine osmolality level, above-normal serum osmolality level
  • 119. 119 78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it? a. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." b. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." c. "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." 79. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders? a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d. Hyperparathyroidism 80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions? a. "I'll take my hydrocortisone in the late afternoon, before dinner." b. "I'll take all of my hydrocortisone in the morning, right after I wake up." c. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." d. "I'll take the entire dose at bedtime." 81. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma? a. High corticotropin and low cortisol levels b. Low corticotropin and high cortisol levels c. High corticotropin and high cortisol levels d. Low corticotropin and low cortisol levels 82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following? a. Testing for ketones in the urine b. Testing urine specific gravity c. Checking temperature every 4 hours d. Performing capillary glucose testing every 4 hours 83. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose's: a. onset to be at 2 p.m. and its peak to be at 3 p.m. b. onset to be at 2:15 p.m. and its peak to be at 3 p.m. c. onset to be at 2:30 p.m. and its peak to be at 4 p.m. d. onset to be at 4 p.m. and its peak to be at 6 p.m. 84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test b. A decreased TSH level c. An increase in the TSH level after 30 minutes during the TSH stimulation test d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay 85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
  • 120. a. "Inject insulin into healthy tissue with large blood vessels and nerves." b. "Rotate injection sites within the same anatomic region, not among different regions." c. "Administer insulin into areas of scar tissue or hypotrophy whenever possible." d. "Administer insulin into sites above muscles that you plan to exercise heavily later that day." 86. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? a. Elevated serum acetone level b. Serum ketone bodies c. Serum alkalosis d. Below-normal serum potassium level 87. For a client with Graves' disease, which nursing intervention promotes comfort? a. Restricting intake of oral fluids b. Placing extra blankets on the client's bed c. Limiting intake of high-carbohydrate foods d. Maintaining room temperature in the low-normal range 88. Patrick is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture? a. Fracture of the distal radius b. Fracture of the olecranon c. Fracture of the humerus d. Fracture of the carpal scaphoid 89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder? a. Calcium and sodium b. Calcium and phosphorous c. Phosphorous and potassium d. Potassium and sodium 90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions? 120 a. Adult respiratory distress syndrome (ARDS) b. Atelectasis c. Bronchitis d. Pneumonia 91. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions? a. Asthma attack b. Atelectasis c. Bronchitis d. Fat embolism 92. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? a. Acute asthma b. Chronic bronchitis c. Pneumonia d. Spontaneous pneumothorax 93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions? a. Bronchitis b. Pneumonia c. Pneumothorax d. Tuberculosis (TB) 94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity? a. The space remains filled with air only b. The surgeon fills the space with a gel c. Serous fluids fills the space and consolidates the region d. The tissue from the other lung grows over to the other side 95. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons? a. Alveolar damage in the infracted area b. Involvement of major blood vessels in the occluded area c. Loss of lung parenchyma d. Loss of lung tissue
  • 121. 121 96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis 97. After a motor vehicle accident, Armand an 22year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling? a. Air leak b. Adequate suction c. Inadequate suction d. Kinked chest tube 98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute? a. 18 b. 21 c. 35 d. 40 99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child? a. 1.2 ml b. 2.4 ml c. 3.5 ml d. 4.2 ml 100. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful? a. “I will wear the stockings until the physician tells me to remove them.” b. “I should wear the stockings even when I am sleep.” c. “Every four hours I should remove the stockings for a half hour.” d. “I should put on the stockings before getting out of bed in the morning.”
  • 122. Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations 1. 2. 3. 4. 5. 6. 7. 8. 9. 122 Answer: (C) Hypertension Rationale: Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection. Answer: (A) Pain Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority. Answer: (D) Decrease the size and vascularity of the thyroid gland. Rationale: Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed. Answer: (A) Liver Disease Rationale: The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen. Answer: (C) Leukopenia Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression. Answer: (C) Avoid foods that in the past caused flatus. Rationale: Foods that bothered a person preoperatively will continue to do so after a colostomy. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.” Rationale: This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated. Answer: (A) Administer Kayexalate Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level. Answer:(B) 28 gtt/min Rationale: This is the correct flow rate; 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) 10. 11. 12. 13. 14. 15. 16. Answer: (D) Upper trunk Rationale: The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%. Answer: (C) Bleeding from ears Rationale: The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation. Answer: (D) may engage in contact sports Rationale: The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. Rationale: COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive. Answer: (B) Facilitate ventilation of the left lung. Rationale: Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. Answer: (A) Food and fluids will be withheld for at least 2 hours. Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours. Answer: (C) hyperkalemia.
  • 123. 123 17. 18. 19. Rationale: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. Answer: (A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. Rationale: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. Answer: (A) The left kidney usually is slightly higher than the right one. Rationale: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5mg/dl. Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also 20. 21. 22. 23. 24. increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%. Answer: (D) Alteration in the size, shape, and organization of differentiated cells Rationale: Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia. Answer: (D) Kaposi's sarcoma Rationale: Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage Rationale: The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias. Answer: (A) Auscultate bowel sounds. Rationale: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort. Answer: (B) Lying on the left side with knees bent Rationale: For a colonoscopy, the nurse initially should position the client on the
  • 124. 25. 26. 27. 28. 124 left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine. Answer: (A) Blood supply to the stoma has been interrupted Rationale: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color. Answer: (A) Applying knee splints Rationale: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder rangeof-motion exercises can prevent contractures in the shoulders, but not in the legs. Answer: (B) Urine output of 20 ml/hour. Rationale: A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit. Answer: (A) Turn him frequently. Rationale: The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, 29. 30. 31. capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position. Answer: (C) In long, even, outward, and downward strokes in the direction of hair growth Rationale: When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation. Answer: (A) Beta -adrenergic blockers Rationale: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload). Answer: (C) Raised 30 degrees Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In
  • 125. 125 32. 33. 34. 35. high Fowler’s position, the veins would be barely discernible above the clavicle. Answer: (D) Inotropic agents Rationale: Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart. Answer: (B) Less than 30% of calories from fat Rationale: A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client. Answer: (C) The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress Rationale: The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality. Answer: (B) Check endotracheal tube placement. Rationale: ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, 36. 37. 38. 39. 40. ventricular fibrillation and atrial flutter – not symptomatic bradycardia. Answer: (C) 95 mm Hg Rationale: Use the following formula to calculate MAP MAP = systolic + 2 (diastolic) 3 MAP=126 mm Hg + 2 (80 mm Hg) 3 MAP=286 mm HG 3 MAP=95 mm Hg Answer: (C) Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel. Rationale: An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias; an electroencephalogram evaluates brain electrical activity. Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT) Rationale: HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells. Answer: (B) Corticosteroids Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation. Answer: (D) Xenogeneic Rationale: An xenogeneic transplant is between is between human and another
  • 126. 41. 42. 43. 44. 45. 126 species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual. Answer: (B) Rationale: Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to IIIa are part of the intrinsic pathway. Answer: (C) Essential thrombocytopenia Rationale: Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency virus. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not polycythemia. Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE. Answer: (B) Night sweat Rationale: In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease. Answer: (D) Breath sounds Rationale: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia. Answer: (B) Muscle spasm Rationale: Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other 46. 47. 48. 49. 50. 51. options, which reflect parts of the nervous system, aren’t usually affected by MM. Answer: (C) 10 years Rationale: Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years. Answer: (A) Low platelet count Rationale: In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places. Answer: (D) Hodgkin’s disease Rationale: Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement. Answer: (C) A Rh-negative Rationale: Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rhnegative blood. It’s important that a person with Rh- negative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions with Rhpositive blood may cause serious reactions with clumping and hemolysis of red blood cells. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and diarrhea”. Rationale: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.
  • 127. 127 52. 53. 54. 55. Rationale: This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed. Rationale: Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours. Answer: (C) Immediately discontinue the infusion Rationale: Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication. Answer: (C) Chronic obstructive bronchitis Rationale: Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic. Answer: (D) Emphysema Rationale: Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with 56. 57. 58. 59. 60. 61. chronic obstructive bronchitis are bloated and cyanotic in appearance. Answer: D 80 mm Hg Rationale: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected. Answer: (C) Respiratory acidosis Rationale: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis. Answer: (C) Respiratory failure Rationale: The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these signs. Answer: (D) Elevated serum aminotransferase Rationale: Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues. Answer: (A) Impaired clotting mechanism Rationale: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism. Answer: (B) Altered level of consciousness Rationale: Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.
  • 128. 62. 63. 64. 65. 128 Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”. Rationale: Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating. Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury. Answer: (D) Apply gloves and assess the groin site Rationale: Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA) Rationale: PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive 66. 67. 68. 69. 70. diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment. Answer: (B) Cardiogenic shock Rationale: Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock. Answer: (C) Kidneys’ excretion of sodium and water Rationale: The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle. Rationale: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensinconverting enzyme inhibitors decrease blood pressure due to their action on angiotensin. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer Rationale: Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE. Answer: (C) Narcotics are avoided after a head injury because they may hide a worsening condition.
  • 129. 129 71. 72. 73. 74. Rationale: Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness. Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) Rationale: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome Rationale: Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care. Answer: (C) Decreases inflammation Rationale: Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization. Answer: (C) Osteoarthritis is the most common form of arthritis Rationale: Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly. 75. 76. 77. 78. Answer: (C) Myxedema coma Rationale: Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening. Answer: (B) An irregular apical pulse Rationale: Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome. Answer: (D) Below-normal urine osmolality level, above-normal serum osmolality level Rationale: In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Rationale: Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral
  • 130. 79. 80. 81. 82. 130 antidiabetic agents usually doesn't need to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low. Answer: (D) Hyperparathyroidism Rationale: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Rationale: Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the bodies own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. Answer: (C) High corticotropin and high cortisol levels Rationale: A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands. Answer: (D) Performing capillary glucose testing every 4 hours Rationale: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't 83. 84. 85. 86. dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m. Rationale: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. Answer: (A) No increase in the thyroidstimulating hormone (TSH) level after 30 minutes during the TSH stimulation test Rationale: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs. Answer: (B) "Rotate injection sites within the same anatomic region, not among different regions." Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily. Answer: (D) Below-normal serum potassium level
  • 131. 131 87. 88. 89. 90. 91. Rationale: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS. Answer: (D) Maintaining room temperature in the low-normal range Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods. Answer: (A) Fracture of the distal radius Rationale: Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid. Answer: (B) Calcium and phosphorous Rationale: In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the development of steoporosis. Answer: (A) Adult respiratory distress syndrome (ARDS) Rationale: Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia. Answer: (D) Fat embolism Rationale: Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. 92. 93. 94. 95. 96. 97. He could develop atelectasis but it typically doesn’t produce progressive hypoxia. Answer: (D) Spontaneous pneumothorax Rationale: A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation. Answer: (C) Pneumothorax Rationale: From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard. Answer: (C) Serous fluids fills the space and consolidates the region Rationale: Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled. Answer: (A) Alveolar damage in the infracted area Rationale: The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung parenchyma and subsequent scar tissue formation. Answer: (D) Respiratory alkalosis Rationale: A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis. Answer: (A) Air leak Rationale: Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air
  • 132. 98. 99. 100. 132 leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber. Answer: (B) 21 Rationale: 3000 x 10 divided by 24 x 60. Answer: (B) 2.4 ml Rationale: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. Answer: (D) “I should put on the stockings before getting out of bed in the morning. Rationale: Promote venous return by applying external pressure on veins.
  • 133. 133 TEST V - Care of Clients with Physiologic and Psychosocial Alterations 1. Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, “You may want to talk about your employment situation in group today.” The Nurse is using which therapeutic technique? a. Observations b. Restating c. Exploring d. Focusing 2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to: a. Check the client’s medical record for an order for an as-needed I.M. dose of medication for agitation. b. Place the client in full leather restraints. c. Call the attending physician and report the behavior. d. Remove all other clients from the dayroom. 3. Tina who is manic, but not yet on medication, comes to the drug treatment center. The nurse would not let this client join the group session because: a. The client is disruptive. b. The client is harmful to self. c. The client is harmful to others. d. The client needs to be on medication first. 4. Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to: a. Inform the mother that she and the father can work through this problem themselves. b. Refer the mother to the hospital social worker. c. Agree to talk with the mother and the father together. d. Suggest that the father and son work things out. 5. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal? a. Perceptual disorders. b. Impending coma. c. Recent alcohol intake. d. Depression with mutism. 6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do? a. Withhold the drug. b. Record the client’s response. c. Encourage the client to tell the doctor. d. Suggest that it takes a while before seeing the results. 7. Dervid, an adolescent has a history of truancy from school, running away from home and “barrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the: a. Id b. Ego c. Superego d. Oedipal complex 8. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect? a. Short-acting anesthesia b. Decreased oral and respiratory secretions. c. Skeletal muscle paralysis. d. Analgesia. 9. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is: a. Serve the client a bowl of soup, buttered French bread, and apple slices. b. Increase calories, decrease fat, and decrease protein. c. Give the client pieces of cut-up steak, carrots, and an apple.
  • 134. d. Increase calories, carbohydrates, and protein. 10. What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse? a. Flat affect b. Expressing guilt c. Acting overly solicitous toward the child. d. Ignoring the child. 11. Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior? a. By designating times during which the client can focus on the behavior. b. By urging the client to reduce the frequency of the behavior as rapidly as possible. c. By calling attention to or attempting to prevent the behavior. d. By discouraging the client from verbalizing anxieties. 12. After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby? a. Recommending a high-protein, low-fat diet. b. Giving sleep medication, as prescribed, to restore a normal sleep- wake cycle. c. Allowing the client time to heal. d. Exploring the meaning of the traumatic event with the client. 13. Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks the nurse, "Why has this happened to me?" What is the nurse's best response? a. "You've developed this paralysis so you can stay with your parents. You must 134 deal with this conflict if you want to walk again." b. "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." c. "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." d. "It isn't uncommon for someone with your personality to develop a conversion disorder during times of stress." 14. Nurse Krina knows that the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD): a. benztropine (Cogentin) and diphenhydramine (Benadryl). b. chlordiazepoxide (Librium) and diazepam (Valium) c. fluvoxamine (Luvox) and clomipramine (Anafranil) d. divalproex (Depakote) and lithium (Lithobid) 15. Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following? a. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days. b. A warning about the incidence of neuroleptic malignant syndrome (NMS). c. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug. d. A warning that immediate sedation can occur with a resultant drop in pulse. 16. Richard with agoraphobia has been symptomfree for 4 months. Classic signs and symptoms of phobias include: a. Insomnia and an inability to concentrate. b. Severe anxiety and fear. c. Depression and weight loss. d. Withdrawal and failure to distinguish reality from fantasy. 17. Which medications have been found to help reduce or eliminate panic attacks?
  • 135. 135 a. b. c. d. Antidepressants Anticholinergics Antipsychotics Mood stabilizers 18. A client seeks care because she feels depressed and has gained weight. To treat her atypical depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical depression, what is its onset of action? a. 1 to 2 days b. 3 to 5 days c. 6 to 8 days d. 10 to 14 days 19. A 65 years old client is in the first stage of Alzheimer's disease. Nurse Patricia should plan to focus this client's care on: a. Offering nourishing finger foods to help maintain the client's nutritional status. b. Providing emotional support and individual counseling. c. Monitoring the client to prevent minor illnesses from turning into major problems. d. Suggesting new activities for the client and family to do together. 20. The nurse is assessing a client who has just been admitted to the emergency department. Which signs would suggest an overdose of an antianxiety agent? a. Combativeness, sweating, and confusion b. Agitation, hyperactivity, and grandiose ideation c. Emotional lability, euphoria, and impaired memory d. Suspiciousness, dilated pupils, and increased blood pressure 21. The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment? a. History of gainful employment b. Frequent expression of guilt regarding antisocial behavior c. Demonstrated ability to maintain close, stable relationships d. A low tolerance for frustration 22. Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: a. Barbiturates b. Amphetamines c. Methadone d. Benzodiazepines 23. Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: a. Delusions b. Hallucinations c. Loose associations d. Neologisms 24. Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? a. Restricts visits with the family and friends until the client begins to eat. b. Provide privacy during meals. c. Set up a strict eating plan for the client. d. Encourage the client to exercise, which will reduce her anxiety. 25. Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis reflects a belief that one is: a. Highly important or famous. b. Being persecuted c. Connected to events unrelated to oneself d. Responsible for the evil in the world. 26. Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic state would include: a. Offering a high-calorie meals and strongly encouraging the client to finish all food. b. Insisting that the client remain active through the day so that he’ll sleep at night. c. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
  • 136. d. Listening attentively with a neutral attitude and avoiding power struggles. 27. Ramon is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using? a. Withdrawal b. Logical thinking c. Repression d. Denial 28. Richard is admitted with a diagnosis of schizotypal personality disorder. hich signs would this client exhibit during social situations? a. Aggressive behavior b. Paranoid thoughts c. Emotional affect d. Independence needs 29. Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: a. Avoid shopping for large amounts of food. b. Control eating impulses. c. Identify anxiety-causing situations d. Eat only three meals per day. 30. Rudolf is admitted for an overdose of amphetamines. When assessing the client, the nurse should expect to see: a. Tension and irritability b. Slow pulse c. Hypotension d. Constipation 31. Nicolas is experiencing hallucinations tells the nurse, “The voices are telling me I’m no good.” The client asks if the nurse hears the voices. The most appropriate response by the nurse would be: a. “It is the voice of your conscience, which only you can control.” b. “No, I do not hear your voices, but I believe you can hear them”. c. “The voices are coming from within you and only you can hear them.” d. “Oh, the voices are a symptom of your illness; don’t pay any attention to them.” 136 32. The nurse is aware that the side effect of electroconvulsive therapy that a client may experience: a. Loss of appetite b. Postural hypotension c. Confusion for a time after treatment d. Complete loss of memory for a time 33. A dying male client gradually moves toward resolution of feelings regarding impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to use nonverbal interventions when assessment reveals that the client is in the: a. Anger stage b. Denial stage c. Bargaining stage d. Acceptance stage 34. The outcome that is unrelated to a crisis state is: a. Learning more constructive coping skills b. Decompensation to a lower level of functioning. c. Adaptation and a return to a prior level of functioning. d. A higher level of anxiety continuing for more than 3 months. 35. Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against: a. Driving at night b. Staying in the sun c. Ingesting wines and cheeses d. Taking medications containing aspirin 36. Jen a nursing student is anxious about the upcoming board examination but is able to study intently and does not become distracted by a roommate’s talking and loud music. The student’s ability to ignore distractions and to focus on studying demonstrates: a. Mild-level anxiety b. Panic-level anxiety c. Severe-level anxiety d. Moderate-level anxiety 37. When assessing a premorbid personality characteristic of a client with a major depression, it would be unusual for the nurse to find that this client demonstrated: a. Rigidity b. Stubbornness
  • 137. 137 c. Diverse interest d. Over meticulousness 38. Nurse Krina recognizes that the suicidal risk for depressed client is greatest: a. As their depression begins to improve b. When their depression is most severe c. Before any type of treatment is started d. As they lose interest in the environment 39. Nurse Kate would expect that a client with vascular dementis would experience: a. Loss of remote memory related to anoxia b. Loss of abstract thinking related to emotional state c. Inability to concentrate related to decreased stimuli d. Disturbance in recalling recent events related to cerebral hypoxia. 40. Josefina is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include: a. Advising the client to watch the diet carefully b. Suggesting that the client take the pills with milk c. Reminding the client that a CBC must be done once a month. d. Encouraging the client to have blood levels checked as ordered. 41. The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be aware that the teachings about the side effects of this drug were understood when the client state, “I will call my doctor immediately if I notice any: a. Sensitivity to bright light or sun b. Fine hand tremors or slurred speech c. Sexual dysfunction or breast enlargement d. Inability to urinate or difficulty when urinating 42. Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a critical care area is: a. Privacy b. Respect c. Empathy d. Presence 43. When establishing an initial nurse-client relationship, Nurse Hazel should explore with the client the: a. Client’s perception of the presenting problem. b. Occurrence of fantasies the client may experience. c. Details of any ritualistic acts carried out by the client d. Client’s feelings when external; controls are instituted. 44. Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that learning has occurred when the client states, “I will avoid: a. Citrus fruit, tuna, and yellow vegetables.” b. Chocolate milk, aged cheese, and yogurt’” c. Green leafy vegetables, chicken, and milk.” d. Whole grains, red meats, and carbonated soda.” 45. Nurse John is a aware that most crisis situations should resolve in about: a. 1 to 2 weeks b. 4 to 6 weeks c. 4 to 6 months d. 6 to 12 months 46. Nurse Judy knows that statistics show that in adolescent suicide behavior: a. Females use more dramatic methods than males b. Males account for more attempts than do females c. Females talk more about suicide before attempting it d. Males are more likely to use lethal methods than are females 47. Dervid with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate? a. "Your behavior won't be tolerated. Go to your room immediately."
  • 138. b. "You're just doing this to get back at me for making you come to therapy." c. "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." d. "I'm disappointed in you. You can't control yourself even for a few minutes." 48. Nurse Maureen knows that the nonantipsychotic medication used to treat some clients with schizoaffective disorder is: a. phenelzine (Nardil) b. chlordiazepoxide (Librium) c. lithium carbonate (Lithane) d. imipramine (Tofranil) 49. Which information is most important for the nurse Trinity to include in a teaching plan for a male schizophrenic client taking clozapine (Clozaril)? a. Monthly blood tests will be necessary. b. Report a sore throat or fever to the physician immediately. c. Blood pressure must be monitored for hypertension. d. Stop the medication when symptoms subside. 50. Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life- threatening reaction: a. Tardive dyskinesia. b. Dystonia. c. Neuroleptic malignant syndrome. d. Akathisia. 51. Which nursing intervention would be most appropriate if a male client develop orthostatic hypotension while taking amitriptyline (Elavil)? a. Consulting with the physician about substituting a different type of antidepressant. b. Advising the client to sit up for 1 minute before getting out of bed. c. Instructing the client to double the dosage until the problem resolves. d. Informing the client that this adverse reaction should disappear within 1 week. 138 52. Mr. Cruz visits the physician's office to seek treatment for depression, feelings of hopelessness, poor appetite, insomnia, fatigue, low self- esteem, poor concentration, and difficulty making decisions. The client states that these symptoms began at least 2 years ago. Based on this report, the nurse Tyfany suspects: a. Cyclothymic disorder. b. Atypical affective disorder. c. Major depression. d. Dysthymic disorder. 53. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps) to be administered by mouth immediately. Before administering the dose, the nurse verifies the dosage ordered. What is the usual minimum dose of activated charcoal? a. 5 g mixed in 250 ml of water b. 15 g mixed in 500 ml of water c. 30 g mixed in 250 ml of water d. 60 g mixed in 500 ml of water 54. What herbal medication for depression, widely used in Europe, is now being prescribed in the United States? a. Ginkgo biloba b. Echinacea c. St. John's wort d. Ephedra 55. Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? a. Clcium b. Sodium c. Chloride d. Potassium 56. Nurse Josefina is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? a. It's characterized by an acute onset and lasts about 1 month. b. It's characterized by a slowly evolving onset and lasts about 1 week. c. It's characterized by a slowly evolving onset and lasts about 1 month. d. It's characterized by an acute onset and lasts hours to a number of days.
  • 139. 139 57. Edward, a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for: a. Occasional irritable outbursts. b. Impaired communication. c. Lack of spontaneity. d. Inability to perform self-care activities. 58. Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that: a. This medication may be habit forming and will be discontinued as soon as the client feels better. b. This medication has no serious adverse effects. c. The client should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication. d. This medication may initially cause tiredness, which should become less bothersome over time. 59. Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to: a. Severely restrict the client's physical activities. b. Weigh the client daily, after the evening meal. c. Monitor vital signs, serum electrolyte levels, and acid-base balance. d. Instruct the client to keep an accurate record of food and fluid intake. 60. Celia with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? a. Alcohol withdrawal b. Cannibis withdrawal c. Cocaine withdrawal d. Opioid withdrawal 61. Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism? a. Regression b. Projection c. Reaction-formation d. Intellectualization 62. Nurse Anne is caring for a client who has been treated long term with antipsychotic medication. During the assessment, Nurse Anne checks the client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely observe: a. Abnormal movements and involuntary movements of the mouth, tongue, and face. b. Abnormal breathing through the nostrils accompanied by a “thrill.” c. Severe headache, flushing, tremors, and ataxia. d. Severe hypertension, migraine headache, 63. Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms? a. Weakness b. Diarrhea c. Blurred vision d. Fecal incontinence 64. Nurse Jannah is monitoring a male client who has been placed inrestraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when: a. The client verbalizes the reasons for the violent behavior. b. The client apologizes and tells the nurse that it will never happen again. c. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. d. The administered medication has taken effect.
  • 140. 65. Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse: a. Increased attention span and concentration b. Increase in appetite c. Sleepiness and lethargy d. Bradycardia and diarrhea a. Revealing personal information to the client b. Focusing on the feelings of the client. c. Confronting the client about discrepancies in verbal or non-verbal behavior d. The client feels angry towards the nurse who resembles his mother. 66. Kitty, a 9 year old child has very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: a. Profound b. Mild c. Moderate d. Severe 72. Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in-charge do first: a. Recognize this as a drug interaction b. Give the client Cogentin c. Reassure the client that these are common side effects of lithium therapy d. Hold the next dose and obtain an order for a stat serum lithium level 67. The therapeutic approach in the care of Armand an autistic child include the following EXCEPT: a. Engage in diversionary activities when acting -out b. Provide an atmosphere of acceptance c. Provide safety measures d. Rearrange the environment to activate the child 68. Jeremy is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with irritated nasal septum. a. Heroin b. Cocaine c. LSD d. Marijuana 69. Nurse Pauline is aware that Dementia unlike delirium is characterized by: a. Slurred speech b. Insidious onset c. Clouding of consciousness d. Sensory perceptual change 70. A 35 year old female has intense fear of riding an elevator. She claims “ As if I will die inside.” The client is suffering from: a. Agoraphobia b. Social phobia c. Claustrophobia d. Xenophobia 71. Nurse Myrna develops a counter-transference reaction. This is evidenced by: 140 73. Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu? a. A therapy that rewards adaptive behavior b. A cognitive approach to change behavior c. A living, learning or working environment. d. A permissive and congenial environment 74. Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting: a. Splitting b. Transference c. Countertransference d. Resistance 75. Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: a. Situational b. Adventitious c. Developmental d. Internal 76. Nurse Greta is aware that the following is classified as an Axis I disorder by the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR) is: a. Obesity b. Borderline personality disorder c. Major depression d. Hypertension
  • 141. 141 77. Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena? a. Intellectualization b. Transference c. Triangulation d. Splitting 78. An 83year-old male client is in extended care facility is anxious most of the time and frequently complains of a number of vague symptoms that interfere with his ability to eat. These symptoms indicate which of the following disorders? a. Conversion disorder b. Hypochondriasis c. Severe anxiety d. Sublimation 79. Charina, a college student who frequently visited the health center during the past year with multiple vague complaints of GI symptoms before course examinations. Although physical causes have been eliminated, the student continues to express her belief that she has a serious illness. These symptoms are typically of which of the following disorders? a. Conversion disorder b. Depersonalization c. Hypochondriasis d. Somatization disorder 80. Nurse Daisy is aware that the following pharmacologic agents are sedative- hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is: a. Triazolam (Halcion) b. Paroxetine (Paxil) c. Fluoxetine (Prozac) d. Risperidone (Risperdal) 81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of the following statement refers to a secondary gain? a. It brings some stability to the family b. It decreases the preoccupation with the physical illness c. It enables the client to avoid some unpleasant activity d. It promotes emotional support or attention for the client 82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the nurse in-charge about the progress made in treatment. Which of the following statements indicates a positive client response? a. “I went to the mall with my friends last Saturday” b. “I’m hyperventilating only when I have a panic attack” c. “Today I decided that I can stop taking my medication” d. “Last night I decided to eat more than a bowl of cereal” 83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder can be demonstrated by which of the following client self –reports? a. “I’m sleeping better and don’t have nightmares” b. “I’m not losing my temper as much” c. “I’ve lost my craving for alcohol” d. I’ve lost my phobia for water” 84. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication? a. Stopping the drug may cause depression b. Stopping the drug increases cognitive abilities c. Stopping the drug decreases sleeping difficulties d. Stopping the drug can cause withdrawal symptoms 85. Jennifer, an adolescent who is depressed and reported by his parents as having difficulty in school is brought to the community mental health center to be evaluated. Which of the following other health problems would the nurse suspect? a. Anxiety disorder b. Behavioral difficulties c. Cognitive impairment d. Labile moods
  • 142. 86. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic disorder. Which of the following statement about dysthymic disorder is true? a. It involves a mood range from moderate depression to hypomania b. It involves a single manic depression c. It’s a form of depression that occurs in the fall and winter d. It’s a mood disorder similar to major depression but of mild to moderate severity 87. The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is: a. Vascular dementia has more abrupt onset b. The duration of vascular dementia is usually brief c. Personality change is common in vascular dementia d. The inability to perform motor activities occurs in vascular dementia 88. Loretta, a newly admitted client was diagnosed with delirium and has history of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), and diazepam (Valium) for anxiety. This client’s impairment may be related to which of the following conditions? a. Infection b. Metabolic acidosis c. Drug intoxication d. Hepatic encephalopathy 89. Nurse Ron enters a client’s room, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the following assessment is the most accurate? a. The client is experiencing aphasia b. The client is experiencing dysarthria c. The client is experiencing a flight of ideas d. The client is experiencing visual hallucination 90. Which of the following descriptions of a client’s experience and behavior can be assessed as an illusion? a. The client tries to hit the nurse when vital signs must be taken b. The client says, “I keep hearing a voice telling me to run away” 142 c. The client becomes anxious whenever the nurse leaves the bedside d. The client looks at the shadow on a wall and tells the nurse she sees frightening faces on the wall. 91. During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder? a. Flight of ideas b. Concrete thinking c. Ideas of reference d. Loose association 92. Francis tells the nurse that her coworkers are sabotaging the computer. When the nurse asks questions, the client becomes argumentative. This behavior shows personality traits associated with which of the following personality disorder? a. Antisocial b. Histrionic c. Paranoid d. Schizotypal 93. Which of the following interventions is important for a Cely experiencing with paranoid personality disorder taking olanzapine (Zyprexa)? a. Explain effects of serotonin syndrome b. Teach the client to watch for extrapyramidal adverse reaction c. Explain that the drug is less affective if the client smokes d. Discuss the need to report paradoxical effects such as euphoria 94. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed with antisocial personality disorder. When discussing appropriate behavior in group therapy, which of the following comments is expected about this client by his peers? a. Lack of honesty b. Belief in superstition c. Show of temper tantrums d. Constant need for attention 95. Tommy, with dependent personality disorder is working to increase his self- esteem. Which of the following statements by the Tommy shows teaching was successful?
  • 143. 143 a. “I’m not going to look just at the negative things about myself” b. “I’m most concerned about my level of competence and progress” c. “I’m not as envious of the things other people have as I used to be” d. “I find I can’t stop myself from taking over things other should be doing” 96. Norma, a 42-year-old client with a diagnosis of chronic undifferentiated schizophrenia lives in a rooming house that has a weekly nursing clinic. She scratches while she tells the nurse she feels creatures eating away at her skin. Which of the following interventions should be done first? a. Talk about his hallucinations and fears b. Refer him for anticholinergic adverse reactions c. Assess for possible physical problems such as rash d. Call his physician to get his medication increased to control his psychosis 97. Ivy, who is on the psychiatric unit is copying and imitating the movements of her primary nurse. During recovery, she says, “I thought the nurse was my mirror. I felt connected only when I saw my nurse.” This behavior is known by which of the following terms? a. Modeling b. Echopraxia c. Ego-syntonicity d. Ritualism 98. Jun approaches the nurse and tells that he hears a voice telling him that he’s evil and deserves to die. Which of the following terms describes the client’s perception? a. Delusion b. Disorganized speech c. Hallucination d. Idea of reference 99. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by mike? a. Projection b. Rationalization c. Regression d. Repression 100. Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol? a. Should report feelings of restlessness or agitation at once b. Use a sunscreen outdoors on a yearround basis c. Be aware you’ll feel increased energy taking this drug d. This drug will indirectly control essential hypertension
  • 144. Answers and Rationale – Care of Clients with Physiologic and Psychosocial Alterations 1. Answer: (D) Focusing Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. The nurse didn’t restate the question, make observation, or ask further question (exploring). 2. Answer: (D) Remove all other clients from the dayroom. Rationale: The nurse’s first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other clients. 3. Answer: (A) The client is disruptive. Rationale: Group activity provides too much stimulation, which the client will not be able to handle (harmful to self) and as a result will be disruptive to others. 4. Answer: (C) Agree to talk with the mother and the father together. Rationale: By agreeing to talk with both parents, the nurse can provide emotional support and further assess and validate the family’s needs. 5. Answer: (A) Perceptual disorders. Rationale: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal. 6. Answer: (D) Suggest that it takes a while before seeing the results. Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached. 7. Answer: (C) Superego Rationale: This behavior shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego. 8. Answer: (C) Skeletal muscle paralysis. Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation. 9. Answer: (D) Increase calories, carbohydrates, and protein. Rationale: This client increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates). 10. Answer: (C) Acting overly solicitous toward the child. 144 Rationale: This behavior is an example of reaction formation, a coping mechanism. 11. Answer: (A) By designating times during which the client can focus on the behavior. Rationale: The nurse should designate times during which the client can focus on the compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror in the client. The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior. 12. Answer: (D) Exploring the meaning of the traumatic event with the client. Rationale: The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. The client must explore the meaning of the event and won't heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep. The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem. 13. Answer: (C) "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." Rationale: The nurse must be honest with the client by telling her that the paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After the psychological conflict is resolved, her symptoms will disappear. Saying that it must be awful not to be able to move her legs wouldn't answer the client's question; knowing that the cause is psychological wouldn't necessarily make her feel better. Telling her that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict.
  • 145. 145 14. Answer: (C) fluvoxamine (Luvox) and clomipramine (Anafranil) Rationale: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. The other medications mentioned aren't effective in the treatment of OCD. 15. Answer: (A) A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days. Rationale: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported. 16. Answer: (B) Severe anxiety and fear. Rationale: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia, and elevated blood pressure. Insomnia, an inability to concentrate, and weight loss are common in depression. Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia. 17. Answer: (A) Antidepressants Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks isn't clearly understood. Anticholinergic agents, which are smoothmuscle relaxants, relieve physical symptoms of anxiety but don't relieve the anxiety itself. Antipsychotic drugs are inappropriate because clients who experience panic attacks aren't psychotic. Mood stabilizers aren't indicated because panic attacks are rarely associated with mood changes. 18. Answer: (B) 3 to 5 days Rationale: Monoamine oxidase inhibitors, such as tranylcypromine, have an onset of action of approximately 3 to 5 days. A full clinical response may be delayed for 3 to 4 weeks. The therapeutic effects may continue for 1 to 2 weeks after discontinuation. 19. Answer: (B) Providing emotional support and individual counseling. 20. 21. 22. 23. Rationale: Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. The other options are appropriate during the second stage of Alzheimer's disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition. Answer: (C) Emotional lability, euphoria, and impaired memory Rationale: Signs of antianxiety agent overdose include emotional lability, euphoria, and impaired memory. Phencyclidine overdose can cause combativeness, sweating, and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure. Answer: (D) A low tolerance for frustration Rationale: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control. They commonly have a history of unemployment, miss work repeatedly, and quit work without other plans for employment. They don't feel guilt about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships. Answer: (C) Methadone Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn’t have the same deterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. Answer: (B) Hallucinations Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client
  • 146. 24. 25. 26. 27. 28. 146 accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client. Answer: (C) Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the client’s weight are very important in this disorder. The family and friends should be included in the client’s care. The client should be monitored during meals-not given privacy. Exercise must be limited and supervised. Answer: (A) Highly important or famous. Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. Answer: (D) Listening attentively with a neutral attitude and avoiding power struggles. Rationale: The nurse should listen to the client’s requests, express willingness to seriously consider the request, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn’t try to restrain the client when he feels the need to move around as long as his activity isn’t harmful. High calorie finger foods should be offered to supplement the client’s diet, if he can’t remain seated long enough to eat a complete meal. The nurse shouldn’t be forced to stay seated at the table to finid=sh a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice. Answer: (D) Denial Rationale: Denial is unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association. Answer: (B) Paranoid thoughts Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive 29. 30. 31. 32. 33. 34. 35. 36. 37. behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships. Answer: (C) Identify anxiety-causing situations Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Answer: (A) Tension and irritability Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increase the heart rate and blood flow. Diarrhea is a common adverse effect so option D is incorrect. Answer: (B) “No, I do not hear your voices, but I believe you can hear them”. Rationale: The nurse, demonstrating knowledge and understanding, accepts the client’s perceptions even though they are hallucinatory. Answer: (C) Confusion for a time after treatment Rationale: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Answer: (D) Acceptance stage Rationale: Communication and intervention during this stage are mainly nonverbal, as when the client gestures to hold the nurse’s hand. Answer: (D) A higher level of anxiety continuing for more than 3 months. Rationale: This is not an expected outcome of a crisis because by definition a crisis would be resolved in 6 weeks. Answer: (B) Staying in the sun Rationale: Haldol causes photosensitivity. Severe sunburn can occur on exposure to the sun. Answer: (D) Moderate-level anxiety Rationale: A moderately anxious person can ignore peripheral events and focuses on central concerns. Answer: (C) Diverse interest Rationale: Before onset of depression, these clients usually have very narrow, limited interest.
  • 147. 147 38. Answer: (A) As their depression begins to improve Rationale: At this point the client may have enough energy to plan and execute an attempt. 39. Answer: (D) Disturbance in recalling recent events related to cerebral hypoxia. Rationale: Cell damage seems to interfere with registering input stimuli, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure. 40. Answer: (D) Encouraging the client to have blood levels checked as ordered. Rationale: Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels. 41. Answer: (B) Fine hand tremors or slurred speech Rationale: These are common side effects of lithium carbonate. 42. Answer: (D) Presence Rationale: The constant presence of a nurse provides emotional support because the client knows that someone is attentive and available in case of an emergency. 43. Answer: (A) Client’s perception of the presenting problem. Rationale: The nurse can be most therapeutic by starting where the client is, because it is the client’s concept of the problem that serves as the starting point of the relationship. 44. Answer: (B) Chocolate milk, aged cheese, and yogurt’” Rationale: These high-tyramine foods, when ingested in the presence of an MAO inhibitor, cause a severe hypertensive response. 45. Answer: (B) 4 to 6 weeks Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks. 46. Answer: (D) Males are more likely to use lethal methods than are females Rationale: This finding is supported by research; females account for 90% of suicide attempts but males are three times more successful because of methods used. 47. Answer: (C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." Rationale: The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended, as in 48. 49. 50. 51. option A. Option B is incorrect because it implies that the client’s actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as option D, may decrease the client's self-esteem. Answer: (C) lithium carbonate (Lithane) Rationale: Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including maniclike activity. Lithium helps control the affective component of this disorder. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and that undergoing cocaine detoxification. Answer: (B) Report a sore throat or fever to the physician immediately. Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. Answer: (C) Neuroleptic malignant syndrome. Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a lifethreatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Answer: (B) Advising the client to sit up for 1 minute before getting out of bed. Rationale: To minimize the effects of amitriptyline-induced orthostatic hypotension,
  • 148. 52. 53. 54. 55. 148 the nurse should advise the client to sit up for 1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases, the dosage may be reduced or the physician may prescribe nortriptyline, another tricyclic antidepressant. Orthostatic hypotension disappears only when the drug is discontinued. Answer: (D) Dysthymic disorder. Rationale: Dysthymic disorder is marked by feelings of depression lasting at least 2 years, accompanied by at least two of the following symptoms: sleep disturbance, appetite disturbance, low energy or fatigue, low selfesteem, poor concentration, difficulty making decisions, and hopelessness. These symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to a few weeks. Cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration marked by numerous periods of depression and hypomania. Atypical affective disorder is characterized by manic signs and symptoms. Major depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, with signs and symptoms recurring for at least 2 weeks. Answer: (C) 30 g mixed in 250 ml of water Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the estimated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed in 250 ml of water. Doses less than this will be ineffective; doses greater than this can increase the risk of adverse reactions, although toxicity doesn't occur with activated charcoal, even at the maximum dose. Answer: (C) St. John's wort Rationale: St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant that is similar to ephedrine. Answer: (B) Sodium Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body 56. 57. 58. 59. functions but sodium is most important to the absorption of lithium. Answer: (D) It's characterized by an acute onset and lasts hours to a number of days Rationale: Delirium has an acute onset and typically can last from several hours to several days. Answer: (B) Impaired communication. Rationale: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer's disease. During the early stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. During the late stage, the client can't perform self-care activities and may become mute. Answer: (D) This medication may initially cause tiredness, which should become less bothersome over time. Rationale: Sedation is a common early adverse effect of imipramine, a tricyclic antidepressant, and usually decreases as tolerance develops. Antidepressants aren't habit forming and don't cause physical or psychological dependence. However, after a long course of high-dose therapy, the dosage should be decreased gradually to avoid mild withdrawal symptoms. Serious adverse effects, although rare, include myocardial infarction, heart failure, and tachycardia. Dietary restrictions, such as avoiding aged cheeses, yogurt, and chicken livers, are necessary for a client taking a monoamine oxidase inhibitor, not a tricyclic antidepressant. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate
  • 149. 149 60. 61. 62. 63. 64. than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately. Answer: (D) Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation. Answer: (A) Regression Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event. Answer: (A) Abnormal movements and involuntary movements of the mouth, tongue, and face. Rationale: Tardive dyskinesia is a severe reaction associated with long term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (fly catcher tongue), and face. Answer: (C) Blurred vision Rationale: At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrythmias, peripheral vascular collapse, and death. Answer: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Rationale: The best indicator that the behavior is controlled, if the client exhibits no signs of aggression after partial release of restraints. Options , B, and D do not ensure that the client has controlled the behavior. 65. Answer: (A) increased attention span and concentration Rationale: The medication has a paradoxic effect that decreases hyperactivity and impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, diarrhea and irritability. 66. Answer: (C) Moderate Rationale: The child with moderate mental retardation has an I.Q. of 35- 50 Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation has an I.Q. of 20-35. 67. Answer: (D) Rearrange the environment to activate the child Rationale: The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. A. Angry outburst can be re-channeling through safe activities. B. Acceptance enhances a trusting relationship. C. Ensure safety from self-destructive behaviors like head banging and hair pulling. 68. Answer: (B) cocaine Rationale: The manifestations indicate intoxication with cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs D. Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment and hallucinations. 69. Answer: (B) insidious onset Rationale: Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium. 70. Answer: (C) Claustrophobia Rationale: Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. D. Xenophobia is fear of strangers. 71. Answer: (A) Revealing personal information to the client Rationale: Counter-transference is an emotional reaction of the nurse on the client based on her
  • 150. 72. 73. 74. 75. 76. 150 unconscious needs and conflicts. B and C. These are therapeutic approaches. D. This is transference reaction where a client has an emotional reaction towards the nurse based on her past. Answer: (D) Hold the next dose and obtain an order for a stat serum lithium level Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia. Answer: (C) A living, learning or working environment. Rationale: 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. The six environmental elements include structure, safety, norms; limit setting, balance and unit modification. A. Behavioral approach in psychiatric care is based on the premise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to change behavior is done by correcting distorted perceptions and irrational beliefs to correct maladaptive behaviors. D. This is not congruent with therapeutic milieu. Answer: (B) Transference Rationale: Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another A. 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. Countert-transference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient D. Resistance is the client’s refusal to submit himself to the care of the nurse Answer: (B) Adventitious Rationale: Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life. A. Situational crisis is from an external source that upset ones psychological equilibrium C and D. are the same. They are transitional or developmental periods in life Answer: (C) Major depression 77. 78. 79. 80. 81. Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder. Borderline personality disorder as an Axis II; obesity and hypertension, Axis III. Answer: (B) Transference Rationale: Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the client’s past to another person. Intellectualization is a defense mechanism in which the client avoids dealing with emotions by focusing on facts. Triangulation refers to conflicts involving three family members. Splitting is a defense mechanism commonly seen in clients with personality disorder in which the world is perceived as all good or all bad. Answer: (B) Hypochondriasis Rationale: Complains of vague physical symptoms that have no apparent medical causes are characteristic of clients with hypochondriasis. In many cases, the GI system is affected. Conversion disorders are characterized by one or more neurolog